PSYCHIATRIC MANIFESTATIONS OF EPILEPSY

Presented by:

Dr. S.M. Yasir Arafat

Phase A Resident

Psychiatry, BSMMU

May 06, 2014.

Philosophy or science

There is nothing either good or bad but thinking

makes it so

William Shakespeare

Introduction

Epilepsy is the most common chronic neurological

disease

Its not a disease, should be considered as a

symptom of brain diseases

What is epilepsy

Recurrent unprovoked seizure

Caused by uncoordinated neuronal discharge

Is it simple to diagnose

The diagnosis of epilepsy is often difficult

Diagnosis is almost clinical

A correct diagnosis can be particularly difficult

when the ictal and interictal symptoms of epilepsy

are severe manifestations of psychiatric symptoms in

the absence of significant changes in consciousness

and cognitive abilities

Irony of epileptics

A large fraction of patients with seizure disorder

are misdiagnosed and treated inappropriately

About one third of the epileptics are misdiagnosed

in both way

Computerized diagnosis is trying

Why psychiatrists

Psychiatric co morbidity is common in epilepsy

Consideration of an epileptic diagnosis in psychiatric

patients

The psychosocial ramifications of epilepsy

The psychological and cognitive effects of AEDs

Shared pathophysiology

Stigma & psychosocial impairment

Psychiatric aspect

30 to 50 percent of epileptics have psychiatric

difficulties sometime during the course of their illness

The most common behavioral symptom of epilepsy

is a change in personality

Preictal conditions

Autonomic sensations

Increasing tension, anxiety, irritability, fear, panic

Fullness in the stomach, blushing and changes inrespiration

Cognitive sensations

Dreamy states, forced thinking, dejà vu, jamais vu

Affective states

Depression, elation

Classical automatisms

Lip smacking, rubbing, chewing

Ictal conditions

Brief, disorganized, and uninhibited behavior characterizes the ictalevent

The cognitive symptoms include amnesia for the time during theseizure and a period of resolving delirium after the seizure

Transient confusional state, affective disturbances, anxiety,automatism.

On occasion abnormal mental state may be the only sign of non-convulsive status epilepticus

Psychosis- Sudden onset & termination of disturbances

Olfactory & Gustatory hallucination

Relative lack of first rank symptoms

Amnesia for the period of disturbances

Post ictal conditions

Diverse motor, sensory, cognitive & autonomic

symptoms may occur

Post ictal violence may occur

Interictal

Personality Disturbances : patients with epilepsy of

temporal lobe origin

Religiosity

increased participation in overtly religious activities

unusual concern for moral and ethical issues

preoccupation with right and wrong

heightened interest in global and philosophical concerns.

sometimes seem like the prodromal symptoms of

schizophrenia

Interictal- personality disturbances

Viscosity of personality

Most noticeable in a patient's conversation

Slow, serious, ponderous, overly replete with nonessential

details, and often circumstantial

The listener may grow bored but be unable to find a

courteous and successful way to disengage from the

conversation

The speech tendencies, often mirrored in the patient's writing,

result in a symptom known as hypergraphia, which some

clinicians consider virtually pathognomonic for complex

partial epilepsy.

Interictal- personality disturbances

Changes in sexual behavior

Hypersexuality: deviations in sexual interest, transvestism

Hyposexuality: both by a lack of interest in sexual matters

and by reduced sexual arousal

Interictal- continue

Psychotic Symptoms

Interictal psychotic states are more common than

ictal psychoses

Schizophrenia-like interictal episodes can occur in

patients with temporal lobe epilepsy

Risk factors

female gender

left-handedness

the onset of seizures during puberty

a left-sided lesion

Interictal- psychotic symptoms

The onset of psychotic symptoms in epilepsy is

variable

Classically, psychotic symptoms appear in patients

who have had epilepsy for a long time, and the

onset of psychotic symptoms is preceded by the

development of personality changes related to the

epileptic brain activity

Interictal- psychotic symptoms

The most characteristic symptoms of the psychoses

are hallucinations and paranoid delusions

Patients usually remain warm and appropriate in

affect, in contrast to the abnormalities of affect

commonly seen in patients with schizophrenia

The thought disorder symptoms in patients with

psychotic epilepsy are most commonly those

involving conceptualization and circumstantiality,

rather than the classic schizophrenic symptoms of

blocking and looseness

Interictal- continue

Violence

Episodic violence has been a problem in some

patients with epilepsy, especially epilepsy of

temporal and frontal lobe origin.

Whether the violence is a manifestation of the

seizure itself or is of interictal psychopathological

origin is uncertain

Interictal- continue

Mood Disorder Symptoms

Mood disorder symptoms, such as depression andmania, are seen less often in epilepsy than areschizophrenia-like symptoms

The mood disorder symptoms that do occur tend to beepisodic and appear most often when the epileptic fociaffect the temporal lobe of the nondominanthemisphere

The importance of mood disorder symptoms may beattested to by the increased incidence of attemptedsuicide in people with epilepsy

Risk factor of depression in epilepsy

Behavior FH of mood disorder

Focus in temporal or frontal lobe

Left side focus

Psychosocial Perceived stigma

Fear of seizure

Pessimistic attribution style

Decreased social support

Unemployment

Iatrogenic Epileptic surgery

AED- polypharmacy with high serum levels

Interictal- continue

Suicide & deliberate self harm

Diagnosis

A correct diagnosis of epilepsy can be difficult when

the ictal and interictal symptoms of epilepsy are

severe manifestations of psychiatric symptoms in the

absence of significant changes in consciousness and

cognitive abilities

Psychiatrists, must maintain a high level of suspicion

during the evaluation of a new patient even in the

absence of the classic signs and symptoms

Previously diagnosed

The appearance of new psychiatric symptoms should beconsidered as possibly representing an evolution in theirepileptic symptoms

The appearance of psychotic symptoms, mood disordersymptoms, personality changes, symptoms of anxietyshould cause a clinician to evaluate the control of thepatient's epilepsy and to assess the patient for thepresence of an independent mental disorder

Compliance with the anticonvulsant drug regimen and itsadverse effects

When psychiatric symptoms appear in a patient whohas had epilepsy in the past

Not previously diagnosed

Four characteristics should cause to be suspicious :

the abrupt onset of psychosis in a person previously

regarded as psychologically healthy

the abrupt onset of delirium without a recognized

cause

a history of similar episodes with abrupt onset and

spontaneous recovery

a history of previous unexplained falling or fainting

spells

What makes us comfortable

Feature Epileptic Seizures Pseudoseizure

Nocturnal seizure Common Uncommon

Stereotyped aura Usually None

Cyanotic skin changes during seizures Common None

Self-injury Common Rare

Incontinence Common Rare

Postictal confusion Present None

Body movements Tonic or clonic or both Nonstereotyped and

asynchronous

Affected by suggestion No Yes

Queries????

“The important thing is not to stop questioning.

Curiosity has its own reason for existing”

Albert Einstein