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Psychiatric Disorders Associated With Epilepsy

Psychiatric Disorders Associated With Epilepsy

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Published by: Allan Dias on Sep 10, 2011
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Psychiatric Disorders Associated With Epilepsy
Author: Pedro E Hernandez-Frau, MD; Chief Editor: Jose E Cavazos, MD, PhD, FAANmore...
Updated: Jun 8, 2011
Epilepsy is a chronic disorder characterized by seizures, or a paroxysmal brain dysfunction due to excessiveneuronal discharge. Psychiatric and cognitive disturbances are relatively common in epilepsy, especially in refractoryepilepsy.
[1, 2, 3]
Indeed, there is now general agreement that the incidence of neurobehavioral disorders is higher in patients withepilepsy than in the general population (although some authors argue that this apparent overrepresentation is due tosampling errors or inadequate control groups). Many, but not all, authors also accept the proposition that the linkbetween neurobehavioral disorders and temporal lobe or complex partial epilepsy is particularly strong.Edeh and Toone asserted that the difference is between focal epilepsies, both temporal lobe and nontemporal lobe,and primary generalized epilepsy.
In studying the relationship between epilepsy and psychiatric disorders, care must be taken to differentiate betweenthe following:Psychiatric disorders caused by the seizures of the epilepsy - Ictal disorders, postictal disorders, and interictaldisordersEpileptic and psychiatric disorders caused by common brain pathologyEpileptic and psychiatric disorders that happen to coexist in the same patient but are not causally relatedGo toEpilepsy and Seizuresfor an overview of this topic. Additionally, go toPsychogenic Nonepileptic Seizuresfor  complete information on this topic.
Factors in the relationship between epilepsy and behavioral disorders
Mechanisms for a relationship between epilepsy and behavioral disorders include the following:Common neuropathologyGenetic predispositionDevelopmental disturbanceIctal or subictal neurophysiologic effectsInhibition or hypometabolism surrounding the epileptic focusSecondary epileptogenesisAlteration of receptor sensitivitySecondary endocrinologic alterationsPrimary, independent psychiatric illnessConsequence of medical or surgical treatmentConsequence of psychosocial burden of epilepsySchmitz et al found that multiple interacting biologic and psychosocial factors determine the risk for development of either schizophreniform psychoses or major depression in patients with epilepsy and concluded that behavioraldisorders in epilepsy had multiple risk factors and multifactorial etiology.
Role of the neurologist in the psychiatric management of patients with epilepsy
As neurologists, we tend to focus on seizure control, and psychiatric comorbidities are often underestimated.
Psychiatric Disorders Associated With Epilepsyhttp://emedicine.medscape.com/article/1186336-overview1 de 1807/09/11 15:45
Recognizing psychiatric manifestations is an area that needs improvement. Once symptoms are identified, thefollowing questions arise
:Are the symptoms related to the occurrence of seizures (preictal, ictal, postictal)?Are the symptoms related to antiepileptic drugs (AEDs)?Is the onset of symptoms associated with the remission of seizures in patients who had previously failed torespond to AEDs?Because of the phenomenology of epilepsy, the close association between epilepsy and psychiatry has a longhistory. The traditional approach to epilepsy care has been to focus on the seizures and their treatment.Concentrating only on the treatment of the seizures, which occupy only a small proportion of the patient's life, doesnot seem to address many of the issues that have an adverse impact on the quality of life of the patient with epilepsy.Sackellares and Berent stated that comprehensive care of the epileptic patient requires "attention to thepsychological and social consequences of epilepsy as well as to the control of seizures."
Although undoubtedly important in the care of the patient with epilepsy, advances in neurologic diagnosis andtreatment tended to obscure the behavioral manifestations of epilepsy until Gibbs drew attention to the highincidence of behavioral disorders in patients withtemporal lobe epilepsy.
Frequency of psychiatric disorders in patients with epilepsy
Vuilleumier and Jallon estimated that 20-30% of patients with epilepsy have psychiatric disturbances.
Tucker reported that 70% of patients with intractable complex partial seizures had 1 or more diagnoses consistent withDiagnostic and Statistical Manual of Mental Disorders, Revised Third Edition (DSM-III-R); 58% of these patients hada history of depressive episodes, 32% had agoraphobia without panic or other anxiety disorder, and 13% hadpsychoses.
Torta and Keller reported that the risk of psychosis in populations of patients with epilepsy may be 6-12 times that of the general population, with a prevalence of about 7-8% (in patients with treatment-refractory temporal lobe epilepsy,the prevalence has been reported to range from 0-16%).
Differences in the rates may result from differences inpopulations studied, time periods investigated, and diagnostic criteria.The most common psychiatric conditions in epilepsy are depression, anxiety, and psychoses.
[12, 13, 14, 15, 16, 17]
(Seethe Table below.)Table. Prevalence Rates of Psychiatric Disorders in Patients With Epilepsy and the General Population (2007data)
(Open Table in a new window)
Psychiatric DisorderControlsPatients With Epilepsy
Major depressive disorder10.7%17.4%Anxiety disorder11.2%22.8%Mood/anxiety disorder19.6%34.2%Suicidal Ideation13.3%25.0%Others20.7%35.5%The psychiatric symptoms characteristic of the neurobehavioral syndrome of epilepsy (ie, Morel syndrome) tend tobe distinguished in the following ways:Atypical for the psychiatric disorder EpisodicPleomorphic
Case study
A 27-year-old man with history of primary generalized epilepsy not controlled with medical therapy presented to athird neurologist for evaluation. His generalized tonic-clonic seizures began 7 years ago. The patient had a complete
Psychiatric Disorders Associated With Epilepsyhttp://emedicine.medscape.com/article/1186336-overview2 de 1807/09/11 15:45
neurologic workup, with some of the tests repeated a few times. Everything was unremarkable except for interictalgeneralized sharp and wave complexes on electroencephalography. The patient has tried multiple antiepilepticmedications (AEDs) without improvement. He has at least 1-2 seizures per week.Since the diagnosis, the patient has not been very motivated. He did not complete graduate school; has worked onlyat a bookstore, part time; still lives at home; and is uninterested in a relationship or in marriage. His parents fear thathe will not be able to support himself independently in the future. Lately, he is staying at home most of the timebecause he is afraid he will have a seizure.
History and Mental Status Examination
The history and Mental Status Examination (MSE) are the most important diagnostic tools a psychiatrist has toobtain information to make an accurate diagnosis. When patients enter the office, pay close attention to their personal grooming. Other behaviors to note may include patients talking to themselves in the waiting area or perhaps pacing outside the office door. Record all observations.The next step for the interviewer is to establish adequate rapport with the patient by introducing himself or herself.Speak directly to the patient during this introduction, and pay attention to whether the patient is maintaining eyecontact. As the interview progresses, more specific or close-ended questions can be asked to obtain specificinformation needed to complete the interview.At some point during the initial interview, a detailed patient history should be taken. Every component of the patienthistory is crucial to the treatment and care of the patient it identifies. The patient history should begin with identifyingpatient data and the patient's chief complaint or reason for coming to the clinic. This also is where all history of illness is recorded, including psychiatric history, medical history, surgical history, family psychiatric and medicalhistory, medications, and allergies.Following completion of the patient's history, perform the MSE to test specific areas of the patient's spheres of consciousness.Next, the interviewer's task is to define the patient's affect, which will range from expansive (fully animated) to flat (novariation). The patient's speech is then evaluated. Thought process and content are evaluated next, including anyhallucinations or delusions, obsessions or compulsions, phobias, and suicidal or homicidal ideation or intent.Then, the patient's sensorium and cognition are examined, most commonly using the Mini-Mental State Examination.A compilation of all information gathered throughout the interview and MSE leads to the differential diagnosis of thepatient. Once this diagnosis is established, a treatment plan is formulated.
Psychosis is a mental and behavioral disorder causing gross distortion or disorganization of a person’s mentalcapacity, affective response, and capacity to recognize reality, communicate, and relate to others to the degree of interfering with that person’s capacity to cope with the ordinary demands of everyday life.Vuilleumier and Jallon found that 2-9% of patients with epilepsy have psychotic disorders.
Perez and Trimblereported that about half of epileptic patients with psychosis could be diagnosed withschizophrenia.
Kanner states that various classifications have been proposed for the psychoses associated with epilepsy. Heasserts that for the neurologist, the most useful might be that which distinguishes among psychoses closely linked toseizures (ictal or postictal psychosis), those linked to seizure remission (alternative psychosis), psychoses with amore stable and chronic course (such as interictal psychosis), and iatrogenic psychotic processes related toantiepileptic drugs.
Ictal events
Status epilepticus(ie, complex partial status epilepticus and absence status epilepticus) can mimic psychiatricdisorders, including psychosis.
Postictal events
Psychiatric Disorders Associated With Epilepsyhttp://emedicine.medscape.com/article/1186336-overview3 de 1807/09/11 15:45

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