epilepsy and behaviour - an overview
TRANSCRIPT
Epilepsy and Behaviour- An Overview
Dr. Ennapadam.S. KrishnamoorthyMD., DCN, PhD (Lond), FRCP (Lond, Glas, Edin), MAMS (India)
Founder Director
TRIMED I NEUROKRISH
www.trimedtherapy.com I www.neurokrish.com
Epilepsy and Behaviour
“Epilepsy and mental disorder are two states of illness of the very closest relationship; they represent identical pathological conditions in two different areas of the nervous system”
Carl-Friedrich Flemming (1799-1880)
Director of ‘Sachsenberg’
Epidemiology of psychiatric disorders in epilepsy
• Most studies hospital or institution based• Few population based studies• Most studies cross-sectional• More recently cohort studies and nested case-
control studies reported• Estimates of prevalence available but not other
epidemiological indices
Large hospital based studies
• 1971: Currie et al; 49% of 666 patients • 1991: Guruje; 37% of 204 patients • 1993: Mendez et al;Schizophrenia in 9.25%
(epilepsy) vs.. 1.06% (migraine)• 1996: Manchanda et al; 47.3% of 300 patients met
DSM-III-R criteria
Meta-analysis
• Whitman (1984); Dodrill (1986)
Patients with epilepsy
- higher risk of psychopathology than normal controls
- similar to patients with chronic illness
- no differences between TLE and generalised epilepsy
Population Based Studies
• 1960: Pond and Bidwell; 29% of 245 patients had psychological disorders
• 1966: Gudmundsson; 512 (52%) of 987 patients showed mental changes
• 1987: Edeh and Toone; 47.7% of 88 patients emerged as psychiatric cases
• 1996: Cockerell et al; 64 incident cases/ 1 year with acute psychological disorders
Population based studies
• Jalava (1996); 35 year cohort study - 4 fold risk of behavioural disorder epilepsy
• Bredkjaer (1998); Record linkage- epilepsy and psychiatry registers; SIR-schizophreniform psychosis (p<10-8)
• Stefansson (1998): disability register based case-control- epilepsy and somatic illness: no difference
Classification And Diagnosis Of Psychiatric Disorders In Epilepsy
Classification- current status
• Both ILAE & WHO classifications of epilepsy do not code psychiatric disorders
• Both ICD-10 & DSM-IV- “epilepsy” automatically subsumed under “organic” diagnosis category
• Existing descriptions in these classifications often not comparable with psychiatric disorders specific to epilepsy
Ideal classification
• Distinguish epilepsy specific psychiatric disorder from common mental disorder
• Link with the ILAE classification of epilepsy• Code other data of relevance such as EEG and AED
therapy• ILAE Commission on Psychobiology is working
towards developing this
I. The problem of co-morbidity
• Co-morbid behavioural disorders like anxiety and depression are common in epilepsy as in other chronic illnesses
• Do not have specific distinguishing features that separate them from those seen in the community
• Suggestion: Diagnose using ICD-10 and DSM-IV criteria; ignore “organic” label
II. Seizures as psychopathology
• Clinical and sub-clinical seizure activity have psychiatric manifestations
• Correlate clinical state with EEG for diagnosis
- Complex partial status (impaired awareness)
- Simple partial status (aura continua)
- Absence status (spike-wave stupor)
III. Psychiatric disorders specific to epilepsy
Cognitive Dysfunction
Due to epilepsy, its complications or due to anti-epileptic drugs
General or specific difficulties with• memory• language• visuo-spatial ability• sensorimotor and perceptual functions
Management of Cognitive Dysfunction
• Consider role of AED’s either singly or in combination
• Newer AED’s like Topiramate cause considerable cognitive change
• optimise prescription of drugs• Rule out sub-clinical status• Rule out metabolic/infectious cause
Case Vignette
• Male/ 40’s/ refractory TLE• Admitted for investigation and treatment • Rapidly progressive cognitive decline after
admission- dementia screen negative• Acute behavioural disturbance• High ammonia level and characteristic EEG change-
“Valproate Encephalopathy” • reversed with Valproate withdrawal
Psychoses of epilepsy
• Inter-ictal psychosis- unrelated to/ unaffected by seizures; schizophrenia like
• Alternative psychosis- occurs during periods of seizure freedom with forced normalization of EEG
• Post-ictal psychosis- follows cluster/ rarely single seizure; lucid interval of 24-48 hrs; lasts for as long as a month
Psychoses of epilepsy- features
• preserved personality • warm affect• significant component of mood change• paranoid and religious themes• polymorphic in nature• often subtle
Management of Psychoses
• Rule out metabolic or infectious causes/ sub-clinical status
• Post-ictal- prevent seizures; indication for surgery; use Clobazam/ antipsychotics
• Inter-ictal- new antipsychotic drugs (treatment and prophylaxis)
• Alternate- complete seizure freedom is not always an ideal to aspire for
Depression in epilepsy
Symptoms: irritability, depressive moods, anergia, insomnia, atypical pains, anxiety, phobic fears and euphoric moods (3 of 8)
• Interictal dysphoric disorder- unrelated to/ largely unaffected by seizures
• Prodromal dysphoric disorder- indicates the impending onset of seizures
• Postictal dysphoric disorder-follows seizure
Management of Depression
• Link with menstrual periods in women• Role of AED’s• SSRI’s can be used to prevent episodes• Post-ictal dysphoria: control of seizures; consider
using Clobazam as prophylactic• Counselling (sharing information)• Cognitive Behavioural Therapy/ Psychotherapy
Case Vignette
• 32/male/frontal lobe seizures• Topiramate- complete seizure freedom• developed Abulia without mood or psychotic
symptoms• Newer antidepressant and Viagra prescribed by GP• Seizures returned- behaviour normalised
Geschwind Syndrome
Inter-ictal syndrome characterised by • intensified and labile emotionality• viscosity (orderliness, excessive attention to detail
and persistence)• hyposexuality• religiosity• hypergraphia
Sensory- Limbic Hyper-connection
increased electrical activity-temporal lobe
enhanced connection between sensory input and limbic processing
sensory experience suffused with emotional coloration
Geschwind Syndrome and Laterality
RIGHT SIDED FOCUS
(EMOTIVE)
emotionality
elation and sadness
Tendency to ‘polish’ image
LEFT SIDED FOCUS
(IDEATIVE)
sense of personal destiny
philosophical interests
Tendency to ‘tarnish’ image
Geschwind versus Kluver-Bucy
HYPERCONNECTION
EMOTIONAL INTENSITY
VISCOSITY
HYPOSEXUALITY
DISCONNECTION
PLACIDITY
HYPERMETAMOR-PHOSIS
HYPERSEXUALITY
Management of Geschwind Syndrome
• Often positive attributes- meticulous, religious, moral people with high integrity
• When personality traits cause impairment
- consider prophylactic antidepressant in people with inter-ictal dysphoria
- consider prophylactic newer antipsychotic for those with subtle psychotic features, irritability or aggression
The Future
• Well designed population based studies using epilepsy specific measures
• Role of seizures, EEG and anti-epileptic drugs need to be explored
• Need for formal therapeutic trials in epilepsy specific behaviour disorder
• Explore biological link between epilepsy and behaviour
Selected Reading
• M.R.Trimble. The Psychoses of Epilepsy, 1992, Raven Press, New York.
• Krishnamoorthy & Trimble. (Forced Normalization); Lambert & Robertson. (Depression); both inEpilepsia 1999; vol.40 (suppl. 10)
• D.Blumer & O.Devinsky- Evidence for and against temporal lobe syndrome. Neurology 1999; vol.53 (suppl. 2)
