Neuropsychiatric Aspects of Epilepsy

ALIAKBAR ESMAEILI

ASSOCIATE PROFESSOR OF PSYCHIATRY

BIRJAND UNIVERSITY OF MEDICAL SCIENCES

EPIDEMIOLOGY&PSYCHOPATHOLOGY

-There exist a bidirectional relationship between psychiatric disorders and epilepsy.

-20 to 60 percent prevalence of psychiatric problems among epilepsy patients.

-The percentage of epilepsy patients in psychiatric hospitals was also higher than the general prevalence of epilepsy.(5-10 percent).

- Among patients attending epilepsy clinics, approximately 30 percent had a prior psychiatric hospitalization, and 10 to 20 percent were on at least one psychotropic drug.

- the pattern of behavioral changes in seizure patients appear specific to epilepsy.(MMPI-2 despite a lack of difference in overall psychopathology, patients with epilepsy have higher schizophrenia scale and paranoia scale scores than patients with other neurological disabilities.)

EPIDEMIOLOGY&PSYCHOPATHOLOGY

- a special relationship to psychopathology in patients whose seizures emanated from mediobasal temporal lesions.

-60 to 76 percent of adults with epilepsy, regardless of seizure type, have a temporal lobe focus, and many generalized tonic–clonic seizures are secondarily generalized from a temporal lobe focus without a preceding focal dyscognitive seizure.

- psychic auras from the temporal lobe, particularly if associated with negative feelings (e.g., jamais vu and fear), predispose to psychosis or personality disorders.

PSYCHOPATHOLOGY- PSYCHOSIS

- MOOD DISORDER (DEPRESSION)

-SUICIDAL BEHAVIOR

- ANXIETY DISORDER

- SOMATIC SYMPTOMS DISORDER

- PERSONALITY DISORDER

- HYPOSEXUALITY

-DISSOCIATIVE SYMPTOMS

PSYCHOSIS & EPILEPSY Psychosis is the specific psychiatric disorder most clearly associated with epilepsy. The lifelong prevalence of all psychotic disorders among epileptic patients ranges from 7 to 12 percent.

- Approximately a five- to eight-fold greater risk of psychosis for epileptic patients than for the general population.

- Autoantibodies [anti-NMDA, anti–voltage-gated potassium channel (VGKC), and anti-GABA-B receptor (GABAB)]may play a role in psychotic symptoms in epilepsy.

- Regarding lateralization and neuropathology, results from many studies suggest an association of a left-sided focus and hippocampal sclerosis with psychosis.

-PET and SPECT may show predominant left temporal hypometabolism among epilepsy patients with psychosis.

Although some focal dyscognitive seizures originate from the frontal or temporal neocortex and other areas, at least two-thirds of focal dyscognitive seizures and generalized tonic–clonic seizures originate from the mediobasal temporal limbic structures (hippocampus, amygdala, and parahippocampal gyrus).

Depression & Epilepsy- The prevalence of depression in different studies varies from 7.5 to 34 percent of patients with epilepsy. Major depressive episode can be found in up to 20 percent of the patients.

-Those with focal dyscognitive seizures originated from mesial temporal lobe and those with poor seizure control are more likely to have mood disorders.

- Psychological studies also suggest a greater incidence of self-criticism, and depression among epilepsy patients with a left hemisphere focus. Patients with focal dyscognitive seizures of temporal limbic origin also have a higher incidence of depression than patients with other types of seizure disorders

Ictal Features- semipurposeful automatisms and psychic auras, such as mood changes, derealizationand depersonalization and forced thinking.

-Ictal fear (which ranges from a vague apprehension to abject fright, has occurred without any other seizure manifestation)

- ictal depression has extended days or longer after the seizure has passed.

-Some patients have pleasurable auras.( Fyodor Dostoyevsky )

- Some patients may have vivid auditory and visual hallucination during having an epileptic discharge.

-Epileptic patients with forced thinking experience their thoughts as stereotypical, out-of-context, brief, and irrational, but not necessarily as ego dystonic.(rule out OCD)

Cognitive Disorders & Ictal- Cognitive disorders follow status epilepticus with focal, focal dyscognitive, or absence seizures -

- Status epilepticus from focal dyscognitive seizures and absence seizures results in prolonged

alterations of responsiveness.

- With the addition of various ictal auras, focal status epilepticus (epilepsia partialis continua) can appear psychotic.

-Nonconvulsive status epilepticus can also present with immobility, waxy flexibility, and behavioral negativism resembling catatonia.

-EEGs and a therapeutic trial of antiepileptic medications may be the only way to distinguish behavioral disturbances due to nonconvulsive status epilepticus.

-recurrent interictal EEG complexes, known as periodic lateralizing epileptiform discharges,may also be associated with prolonged confusional behavior and focal cognitive changes

Peri-Ictal FeaturesPsychiatric disturbances can occur before seizures (prodromal), after seizures (postictal), or during intermittent seizure activity.

- Some patients experience prodromal symptoms that begin at least 30 minutes before seizure onset, last 10 minutes to 3 days, and are continuous with irritability, depression, headache, confusion, and other symptoms.

-The postictal period is characterized by a confusional state lasting minutes to

hours or, occasionally, days.

-Prolonged, postictal confusion may particularly follow right temporal focal dyscognitive seizures.

- Some “twilight states” result from a protracted period of intermixed ictal and

postictal changes.

Alternating Psychosis

- Peri-ictal psychotic symptoms often worsen with increasing seizure activity. Rarely, psychotic symptoms alternate with seizure activity.

-In this alternating psychosis, when patients are having seizures, they are free of psychotic symptoms, but when they are seizure free and their EEG has forced or paradoxical normalization, they manifest psychotic symptoms.

Postictal Psychosis

- An important peri-ictal psychiatric disorder consists of brief psychotic episodes that follow clusters of generalized tonic–clonic seizures (i.e., postictal psychosis). These psychotic episodes occur in patients who have focal dyscognitive seizures, frequent secondary generalization to tonic clonic seizures, bilateral interictal discharges, and frequent discharges involving the left amygdala.

- Lucid interval of 2 to 72 hours (with a mean of 1 day),

-The postictal psychotic episodes last 16 to 432 hours (with a mean of 3.5 days) and often include grandiose or religious delusions, elevated moods or sudden mood swings, agitation, paranoia, and impulsive behaviors, but no perceptual delusions or voices are heard.

-The postictal psychoses remit spontaneously or with the use of low-dose psychotropic medication.

Interictal Features

- Interictal Psychosis (Schizophreniform/Schizophrenia Like Psychosis)

- Personality Disorders

- Gastaut–Geschwind Syndrome

Interictal Psychosis (Schizophreniform/Schizophrenia Like Psychosis)

- Most psychotic episodes that occur in epilepsy patients are interictal psychosis which usually had no known direct relationship to seizure events or ictal discharge.

-alternating psychosis : The terms alternating psychosis and forced or paradoxical normalization refer to this demonstrable antagonism between the psychosis and the seizures or EEG discharges.

Although a spontaneous resolution of interictal psychosis is not common, it may occur in patients with shorter duration of epilepsy history and later onset of epilepsy.

- This disorder sometimes resembles schizophreniform psychosis, and schizoaffective psychosis with intermixed affective symptoms. In addition, there are prominent paranoid delusions, relative preserved affect, normal premorbid personality, and no family history of schizophrenia.

Personality Disorders-Among epileptic patients, there is a high prevalence of personality disorders, including borderline, atypical or mixed, histrionic, and dependent disorders. Patients with personality disorders tend to show dependent and avoidant personality traits. The most common personality disorder in epilepsy is a borderline personality.

- epileptic patients frequently lack a stable character structure and can be immature and impulsive. This personality constellation partially explains the increased incidence of irritability,suicide attempts, and intermittent explosive disorder. Those with epilepsy

are stigmatized, feared, and subject to difficulties in obtaining a job, driving an automobile, and maintaining a marriage.

- the patients with temporal lobe epilepsy usually have an impairment in ability to understand others feeling, thought, and perspective, also known as “theory of mind (ToM).”

Gastaut–Geschwind Syndrome- Some epilepsy patients with a temporal limbic focus develop a sense of the heightened significance of things. These patients are serious, humorless,and overinclusive, and have an intense interest in philosophical, moral, orreligious issues.

-Viscosity, the tendency to talk repetitively and circumstantially about a restricted range of topics.They can spend a long time getting to the point, give detailed background information with multiple quotations, or write copiously about their thoughts and feelings (hypergraphia). Viscosity may particularly occur in patients with left-sided or bilateral temporal foci.