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 in

respiration 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 ictal event

The cognitive symptoms include amnesia for the time during the seizure 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

and mania, are seen less often in epilepsy than are schizophrenia-like symptoms

The mood disorder symptoms that do occur tend to be episodic and appear most often when the epileptic foci affect the temporal lobe of the nondominant hemisphere

The importance of mood disorder symptoms may be attested to by the increased incidence of attempted suicide 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 be considered as possibly representing an evolution in their epileptic symptoms

The appearance of psychotic symptoms, mood disorder symptoms, personality changes, symptoms of anxiety should cause a clinician to evaluate the control of the patient's epilepsy and to assess the patient for the presence of an independent mental disorder

Compliance with the anticonvulsant drug regimen and its adverse effects

When psychiatric symptoms appear in a patient who has 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