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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