Neuropsychiatric aspect of

Epilepsy
Lydia Seifu (psych RI)
Moderator: Dr Alemayehu MD, Associate
professor, consultant psychiatrist
 Outline
• Definition of terms
• Classification
• Epidemiology
• Psychiatric aspect of epilepsy
• Management approach
 Terms
• Seizure
• Epilepsy
• Peri-ictal
• Ictal
• Post-ictal
• Inter-ictal
• Psychogenic nonepileptic seizures (PNES)
 seizures are sudden, involuntary behavioral
events associated with excessive or
hypersynchronous electrical discharges in the
brain.
 Peri-ictal period refers to the period just
before or after the ictus
 Interictal period refers to the period between
the postictal abnormalities and the next ictus.
Epilepsy : at least two unprovoked seizures
occurring > 24 hr apart.
Status epilepticus:
– ≥5 minutes of continuous seizures
– ≥2 discrete seizures between which there is
incomplete recovery of consciousness
Classification
 Generalized onset seizures are those with an
initial widespread bihemispheric involvement
 Focal onset seizures are those that emanate
from a focus limited to part of one
hemisphere.
Temporal lobe epilepsy is the most common
focal onset epilepsy, and 80% of temporal lobe
epilepsy is mesial (medial) temporal lobe
epilepsy
 Generalized seizures
• Originate at some point
within and rapidly engage
bilaterally distributed
networks
• Can include cortical and
subcortical structures
but not necessarily the
entire cortex
Focal seizures
• Originate within
networks limited
to one hemisphere
• May be discretely
localized
or more widely
distributed.…
 Epidemiology
 Epilepsy affects 20 to 40 million people
worldwide.
 The overall incidence is high in the first year,
drops to a minimum in the third and fourth
decades of life, then peaks after age 75 year.
 Epidemiological studies show a 20 to 60
percent prevalence of psychiatric problems
among epilepsy patients.
 Among patients attending epilepsy clinics,
approximately
 30 percent had a prior psychiatric
hospitalization
 10 to 20 percent were on at least one
psychotropic drug.
PSYCHOPATHOLOGY
 There exist a bidirectional relationship
between psychiatric disorders and epilepsy.
 Many studies found a special relationship to
psychopathology in patients whose seizures
emanated from mediobasal temporal lesions
• There are several potential organic causes of psychiatric
disturbances in epilepsy .
 The pathology itself could be the source of seizures and
behavioral changes.
 Ictal or subictal epileptiform activity may promote behavioral
changes by
-facilitating distributed neuronal connections,
-increasing limbic–sensory associations
-changing the overall balance between excitation
and inhibition.
 The absence or hyperactivity of function, such
as the inter-ictal hypo metabolism observed
on may lead to depression or other interictal
behavioral change,
 seizures may result in neuroendocrine or
neurotransmitter changes, such as:
-increased dopaminergic or inhibitory
transmitters
-decreased prolactin
-increased testosterone
-increased endogenous opioids,
 Epilepsy patients are prone to:
 Psychosis
 Mood disorder(especially depression)
 Anxiety disorder
 Somatic symptom disorders
 Personality disorders
 Hyposexuality and dissociative symptoms.
 Focal seizures that involve subjective sensory
or psychic phenomena without observed
motor or autonomic changes are considered
auras.
 Focal dyscognitive seizures are usually
characterized by motionless staring combined
with simple automatisms, or automatic motor
activity, and last approximately for 1 minute.
Psychosis
-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.
 Autoantibodies may play a role in psychotic
symptoms in epilepsy can be found in up to 10
percent of these patients.
 There is an association of a left-sided focus
and hippocampal sclerosis with psychosis.
 Temporal lobe epilepsy was 7 percent.
Depression
-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.
 Patients with focal dyscognitive seizures of
temporal limbic origin and poor seizure
control are more likely to have mood disorders
a higher incidence of depression than patients
with other types of seizure disorders
Personality Disorders
-There is a high prevalence of personality
disorders among epileptic patients, , including
borderline, atypical or mixed, histrionic, and
dependent disorders.
Gastaut–Geschwind Syndrome
-This occur in patients with focal dyscognitive
seizures.
-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, or religious issues and viscosity.
personality disorders, suicidal behavior,
anxiety disorder, and hyposexuality are more
prevalent among epilepsy patients than
among those without seizure disorders.
Patients with epilepsy are at risk of higher
rates in self-harm, suicidal ideation, and
complete suicide.
The risk of completed suicide in epilepsy
patients is four to five times greater than that
among the non-epileptic population.
 DIAGNOSIS
 Diagnostic and Statistical Manual of Mental
Disorders, 5th edition (DSM5) does not have an
exclusive diagnostic entity for epilepsy-related
mental disorders.
 If the syndrome was clearly associated with epilepsy,
it will fall under “mental disorder due to another
medical condition” diagnosis;
 The other way to categorize psychiatric behaviors
associated with epilepsy is their relationship to the
ictus or seizure discharges.
• Psychosis attributable to epilepsy has been
further differentiated into ictal, postictal, and
interictal psychosis.
• The most common of these is postictal
psychosis, observed in 2%–7.8% of individuals
with epilepsy.
Peri-Ictal Features
• Psychiatric 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 and
last to 3 days before seizure onset.
• These are continuous with irritability,
depression, headache andconfusion.
• The postictal period is characterized by a
confusional state lasting minutes to hours or,
occasionally, days.
Peri-ictal psychotic symptoms often worsen with
increasing seizure activity
In 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.
• This alternating pattern is much less common than
the increased emergence of psychotic behavior with
increasing seizure activity.
Brief psychotic episodes
-important peri-ictal psychiatric disorder that follow
clusters of generalized tonic–clonic seizures (i.e.,
postictal psychosis).
-These psychotic episodes occur in patients who have
• Focal dyscognitive seizures,
• Secondary generalization to tonic-clonic seizures
• bilateral inter-ictal discharges
• discharges involving the left amygdala
 The postictal psychosis of epilepsy emerges after a lucid
interval of 2 to 72 hours (with a mean of 1 day), during
which the immediate postictal confusion resolves, and the
patient appears to return to normal.
• The postictal psychotic episodes last 16hrs to 3months and
it Include :
 grandiose or religious delusions
 elevated moods or sudden mood swings
 Agitation
 paranoia, and impulsive behaviors,
 No perceptual delusions or voices are heard.
The postictal psychoses remit spontaneously
or with the use of low-dose psychotropic
medication.
The duration of treatment will depend on the
time it takes to reach full symptom remission,
after which the dose can be tapered down
over several days.
Ictal Features
• Seizure discharges can produce semi-
purposeful automatisms and psychic auras,
such as mood changes, derealization and
depersonalization, and forced thinking.
Psychic auras from the temporal lobe,
particularly if associated with negative feelings
(e.g., jamais vu and fear), predispose to
psychosis or personality disorders.
• Fyodor Dostoyevsky had
“ecstatic auras” in
which he felt in perfect
harmony with the entire
universe and “would
give 10 years of this life,
perhaps all of it, for a
few seconds of such
bliss.”
Cognitive disorders follow status epilepticus
with focal, focal dyscognitive, or absence
seizures.
Non-convulsive status epilepticus can also
present with immobility, waxy flexibility, and
behavioral negativism resembling catatonia.
Recurrent or prolonged focal seizures if
manifested by psychic auras, may be difficult
to distinguish from primary psychiatric
disturbances.
Ictal panic
-is one of the most frequently misdiagnosed
symptoms in medical practice, as it is often
diagnosed as a panic attack
 Ictal panic
• Brief (<30 seconds)
• Occurs out of context to
concurrent events
• May be followed by
confusion, salivation and
automatisms
• Intensity of fear is mild to
moderate
Panic attack
• 5 to 20 minutes duration
• Associated with
tachycardia, diaphoresis,
SOB, not excessive
salivation
• No real confusion or LOC
• Intense fear
• likely to develop
agoraphobia
Ictal symptoms of depression
-are the second most frequent ictal psychiatric
symptoms
-The most frequent symptoms include feelings
of anhedonia, guilt, and suicidal ideation.
Inter-ictal Features
-Most psychotic episodes that occur in epilepsy
patients are interictal psychosis which usually
had no known direct relationship to seizure
events or ictal discharge.
-Duration of psychotic episodes vary greatly
from days to years, but usually last longer than
1 month in the vast majority of cases.
 Many of these patients develop worsening
psychotic symptoms that are concomitant
with :
 An increase in seizure frequency
 Antiepileptic drug withdrawal
 few others have worsening psychotic
symptoms on control of the seizures
(alternating psychosis).
 The patients with chronic inter-ictal psychosis often have
 Early age of onset of seizures
 A decade or more of poorly controlled partial complex
seizures with secondary generalized tonic–clonic
seizures.
 History of status epilepticus and febrile seizures,
 It may evolve from prior recurrent postictal psychotic
episodes
 It may occur in patients with shorter duration of
epilepsy history and later onset of epilepsy.
Seizure control with antiepileptic drugs or
removal of the seizure focus does not prevent
the development of the interictal psychosis,
which occasionally emerges for the first time
after successful seizure treatment.
This disorder sometimes resembles
schizophreniform psychosis, and
schizoaffective psychosis with intermixed
affective symptoms. there are also
 Prominent paranoid delusions
 Relative preserved affect
 Normal premorbid personality
 No family history of schizophrenia.
 NONEPILEPTIC BEHAVIORAL DISORDERS, OR
PSYCHOGENIC NONEPILEPTIC SEIZURES

• Non-epileptic behavioral disorders, or

psychogenic non-epileptic seizures (PNES) are
involuntary, psychogenically induced spells
that mimic many epileptic behaviors.
• Up to 30 percent of patients with epilepsy are
affected by non-epileptic seizures.
• pseudo seizure is previously used term.
• Differentiating epileptic seizures from nonepileptic
seizures can be difficult based on history alone.
• Video EEG monitoring is the gold standard and can
diagnose nonepileptic seizures with near certainty;
• Approximately 10 to 15 percent of nonepileptic
seizure patients have a true seizure disorder as
well, and nonepileptic seizures may result from the
elaborating or “highlighting” of their epileptic
seizures.
• Patients with nonepileptic seizures are most
commonly women between the ages of 26
and 32 years with psychological stressors and
poor coping skills.
• The most helpful differentiation feature may
be an ictal duration of 2 minutes or more
• Patients with non-epileptic seizures have a
high incidence of prior psychological trauma
such as sexual or physical abuse.
• The patients with nonepileptic seizures also have a
high rate of other psychiatric comorbidities,
especially depressive disorders, dissociative
disorders, anxiety disorders, PTSD, or personality
disorders.
• both depressive disorder and anxiety disorder are
very common in patients with epileptic seizure; but
dissociative disorders, PTSD, and personality
disorders,(esp cluster B personality disorder,) are
more associated with PNES.
• Treatment and Outcomes.
 Overall outcome is mediocre; the course of illness can be
chronic and fluctuate.
 patients who suffered from subtype with pure motor
weakness usually recover in weeks to months, but the
episode also frequently reoccurs.
 The patients with predominant somatic symptoms such as
pain and paresthesia may have a stable course of illness
but it tends to be more chronic.
 The outcome of nonepileptic seizures probably lies
between those two.
• Although most of the patients will have less
frequent nonepileptic seizure episodes after
the treatment, over half of patients do not
achieve remission and remain disabled after
10 years of the symptom onset.
• The outcome may be impacted by
-delayed diagnosis
-lack of access to treatment options.
• Pharmacological treatment alone may not be
effective, despite SSRIs showing some benefits
in some patients.
• It is crucial to deliver a consistent and long-
term care with psychological intervention such
as cognitive behavioral therapy.
Good prognostic indicators
 Higher education
 Younger age of onset and diagnosis
 Events with less dramatic features
 Fewer psychiatric comorbidities,
 Fewer additional psychogenic symptoms
 Lower dissociation scores
 Lower scores on the personality dimensions( in
inhibitedness, emotional dysregulation)
 TREATMENT
• The first concerns the temporal relationship
between seizures and psychiatric disorder
• Ictal psychotic symptoms are simply an
expression of epilepsy. Their importance lies
primarily in recognizing them as epileptic.
• Seizure control will be the focus of
treatment.
Antiepileptic Medications
-In the treatment of psychiatrically disturbed
epileptic patients, a first consideration is the
behavioral effects of antiepileptic medications.
-Lamotrigine is the only antiepileptic that has a
well-established efficacy in preventing
recurrence of depressive episode in bipolar
disorder.
Psychotropic Medications
 Antipsychotics.
-Small number (up to 15 percent) of the interictal
psychosis resolves without any treatment, but a
majority of patients require antipsychotics.
-There are no distinct differences in efficacies
between second generation antipsychotics and
first generation antipsychotics.
 clozapine, olanzapine, quetiapine,
chlorpromazine, thioridazine, and
perphenazine have seizure threshold lowering
effect
 Antidepressants.
• Prescribing antidepressants can alleviate both
anxiety and mood symptoms at the same
time.
• the principle of choosing antidepressants will
be based on adverse effects and tolerability
of the patients.
Drug Interactions
-Most commonly, an antiepileptic drug increases
the metabolism of a psychotropic drug with a
consequent decrease in its therapeutic
efficiency.
-the newer antiepileptic medications have fewer
potential interactions with psychotropic
medications.
In treating the neuropsychiatric disorders of
epilepsy, a final consideration is altering the
seizure management itself.
In addition to the occasional behavior
alleviated by strict seizure control, allowing
seizures under carefully controlled conditions,
much like ECT, may relieve some cases of
peri-ictal psychosis, depression, or other
behaviors.
 Reference
• KAPLAN & SADOCK’S COMPREHENSIVE
TEXTBOOK OF PSYCHIATRY 10th edition
• The Neuropsychiatry of Epilepsy 2nd edition
THANK YOU
• Duration: The duration of an aura can vary, ranging from
a few seconds to several minutes. In some cases, the
aura may blend seamlessly into the subsequent seizure
activity.

• Diagnostic Importance: Auras can provide valuable

diagnostic information to healthcare professionals in
determining the type and localization of the epilepsy.
Certain types of auras are associated with specific
seizure types or epileptic syndromes, which can aid in
the diagnosis and treatment planning.