Epilepsy from psychiatric point of view

Epilepsy from psychiatric point of view

By : Shady Mashaly

Assistant lecturer of psychiatryMansoura Faculty of Medicinedr.shadymashaly@gmail.com

EpilepsyClinical considerationThe term epilepsy is derived from Greek ''epilepsia'': a taking hold or seizing.

Epilepsy is a CNS disorder ch' by: repeated stereotyped unprovoked seizures.

A seizure, is defined as :An abnormal paroxysmal discharge of cerebral neurons sufficient to cause clinically detectable events that are apparent to the patient or an observer.

History of epilepsy:

Ancient accounts over 2,500 years ago by Babylonians and Egyptians. Relation ( ) Epilepsy & Psychiatry:

Approximately half of all patients with seizure disorders have co-morbid psychiatric syndromes.

Classification of EpilepsyClassificationPartialGeneralizedUnclassifiedSPS(no impair consc)CPS = psychomotor2ry GeneralizationAbsenceTonic-ClonicMyoclonic AtonicTonicClonic Reflex WestRolandicEtc,Motor signsSensory symptomsAutonomic symptomsSPS onset then impaired conscious LevelORImpaired consciousness at onsetSPS GCPS G SPS CPS G

Psychiatric Aspects of Epilepsy:- Patients with seizures may have psychiatric symptoms that occur during:

A)seizure (ictal symptoms).B)Immediately before or after a seizure (periictal symptoms). C)between seizures (interictal symptoms).

A) Ictal Neuropsychiatric Phenomena

- Ictal psychiatric symptoms are most commonly associated with partial seizures, although they can also occur with generalized seizures.

- Most Psychiatric manifestations occur in the ictal stage are related to complex partial seizures.

CPSs may involve:A)SensoryB)Affective C)Behavioral D)Cognitive symptoms

A)Sensory (percetual):

Hallucinations of any sensory modality; they can be olfactory (e.g., a noxious odor, like burning rubber), gustatory (metallic or other tastes), auditory, visual, or tactile in nature.

B)Affective:

The most common affective symptoms are fear and anxiety, although depression may also occur; rage is uncommon.

- Ictal depression:

Uncommon; it occurs as part of the aura in approximately 1% of patients with epilepsy.

- Ictal anxiety: will be discussed later .

C)Behavior during CPSs may also be abnormal;

Automatisms are common and may include oral or buccal movements (e.g., lip smacking or chewing), picking behaviors, or prolonged staring.

D)Cognitive symptoms associated with CPS include

Dj vu (a feeling of familiarity), Jamais vu (a feeling of unfamiliarity), and dissociative, or out-of-body, experiences.

Confusing clinical presentations related to anxiety component of CPS:- Anxiety or fear is a component of the aura in one third of patients with partial seizures; the anxiety is often intense and may last throughout the course of the seizure. - It may be most common in patients with (right temporal foci).

- Patients with neuro-psychiatric symptoms secondary to CPS may be mistakenly diagnosed with a primary psychiatric disorder because the symptoms of a CPS are often similar to those of psychiatric disorders.

- Such symptoms may resemble those of panic attacks, with autonomic symptoms, nausea, intense anxiety, and depersonalization.

- The clinical situation may be further confused by the fact that patients with epilepsy have high rates (approximately 20%) of co-morbid panic attacks.

- Therefore patients with epilepsy may have both ictal anxiety and interictal panic attacks that can be difficult to distinguish. - Because CPSs are generally not associated with classic tonicclonic seizure activity, the interictal (and even ictal) scalp electroencephalogram (EEG) may appear normal.

- Ictal psychosis is also common in patients with partial seizures.

- Ictal psychotic symptoms are most often associated with temporal lobe foci, but nearly one third of patients have nontemporal lobe foci.

Some distinguishing characteristics of ictal and nonictal symptoms:

Ictal SymptomsNonictal SymptomsAppearance of SymptomsSudden onset and offsetMore often gradual in natureLength of SymptomsUsually 600 mg/day develop seizures.- If you have to use : better to avoid Carbamazepine for prophylaxis and better to use : lamotirgine or Na Valproate .

7) Depot Anipsychotics:- Avoid although none of the depot preparations currently available is thought to be epileptogenic .- However, the depot may have delayed epileptogenic action due to its kinetics or - If seizure has occurred the offending drug now may not be easily withdrawn- So Depot antipsychotics should be used with extreme caution.

Anti epileptics Used as Mood Stabilizers

A)Carbamazepine & Oxcarbazepine:

Kinetics:- Metabolized into (Carbamazepine epoxide) which is the active (toxic teratogenic)metabolite.

- Vs Oxcarbazepine:Which is metabolized to its active (monohydroxy) metabolite .

- Carbamazepine is potent inducer of CYP 450 enzymes that metabolize wide range of drugs so it metabolizes : lamotigine & phenytoin & topiramate & and valproate.

- It accelerates its own metabolism.- It increases chances of Li+ toxicity so this combination may be unfavorable in some patients.

Indications:1)1st line for partial & GTC seizure.2)Alternative to Li+ in bipolar disorder :has lower efficacy in prophylaxis of (bipolar & Suicidality) than Li+3)Other neurologic indications.Advantages of Oxcarbazepine over carbamazepine (CBZ):1)more rapid titration than CBZ b.i.d dosing , minor interactions, no known hepatic or hematologic adverse reactions

2)Not converted to epoxide metabolite which accounts for most of Side effects of CBZ

B)Valproate:Kinetics:3 forms Free acid, Na salt form , and Divalprox sodium: combination of previous 2.

Interactions:Inhibits metabolism of other drugs e.g: lamotigine, phenobabital and primidone.

It can either increase or decrease Carbamazepine and phenytoin.

Indications:1.Best established broad spectrum Anti-epileptic2.Indicated in rapid cycling bipolar disorder.

Teratogenicty:

CBZ & oxcarbazepine and Valproate in pregnancy:

- Decrease the absorption of folic acid by non competeive mechanism.- Normally the Neural tube is formed on the 18th to 21st days after fertilization and closes by the end of 4th week.

- Serum B-HCG appears (in blood) 1 week after fertilization (around the time of implantation) & appears in (urine) 1 weeks to 2 weeks after implantation.

- Implantation occurs 7-10 days after fertilization.- So most of the time pregnant women know about their pregnancy after the Neural tube has been formed .

- Normal daily requirement of folic acid for pregnant women is ranging from 0.4 to 0.8 mg (400-800 micrograms).- But in women taking Carbamazepine or Valproate it increases by 10 folds.

Folic Acid:

1.Patients with no personal health risks , planned pregnancy, and good compliance require :

A) Good diet of folate rich foods

B) Daily supplementation with multivitamin with folic acid (0.4-1 mg daily) for at least 2-3 months before conception, throughout pregnancy and postpartum period (4-6 weeks or as breast feeding continues) .

2.Patients with high risk including (epilepsy, family history of neural tube defects, insulin dependant D.M, obesity > 35 kg/m2) require:

Increased daily intake of folic acid to 5 mg daily for at least 2-3 months before conception, throughout pregnancy and postpartum period (4-6 weeks or as breast feeding continues) .

3. Women taking a multivitamin containing folic acid should be advised not to take more than one daily dose of vitamin supplement.

References1.Oxford handbook for clinical psychiatry (2013)

2.Handbook of General Hospital (2010)Massachusetts General Hospital, HMS.

3.Maudsley prescribing guidelines, 2013

4.Text book Pharmacology, 2014Oklahoma state university at Tulsa.

5. Samuels therapeutic Neurology (2010)Brigham and women hospital, HMS

6.Human Embryology, 2009

7.Clinical pharmacology during pregnancy, 2013