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Psychiatric manifestations of epilepsy Flashcards

1
Q

Which of the following statements are true

1 in 10 people with epilepsy have a lifetime history of psychiatric disorders
1 in 5 people with epilepsy have a lifetime history of psychiatric disorders
1 in 4 people with epilepsy have a lifetime history of psychiatric disorders
1 in 3 people with epilepsy have a lifetime history of psychiatric disorders
1 in 2 people with epilepsy have a lifetime history of psychiatric disorders

A

1 in 3 people with epilepsy have a lifetime history of psychiatric disorders

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2
Q

FACT

A

1 in 5 people with epilepsy have a 2 to 5 times increased risk of developing a psychiatric disorder

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3
Q

Describe the prevalence of psuchiatric didsorders in people with epilepsy compared to the general population

A

People with epilepsy have an increased risk of major depression and other mood disorders (bipolar, dysthymia and clyclothymia) compared to the general population

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4
Q

Which five pre-existing psychiatric disorders are risk factors for epilepsy?

A
  • depression
  • suicidality
  • ADHD
  • psychosis
  • schizophrenia
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5
Q

What is the likelihood of a hx of depression in people who later develop epilepsy?

A

three to seven times more likely

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6
Q

What are the risk factors for psychiatric disorders in adults with epilepsy?

A
  • generalised epilepsy
  • higher seizure frequency
  • outpatient appointments
  • emergency admission
  • hospitalisation
  • older age
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7
Q

A lifetime hx of psychiatric comorbidities in people with epilepsy is associated with which two adverse outcomes?

A
  1. poor tolerance of anti seizure medications
  2. complications related medication or surgery
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8
Q

Which anti seizure medications are associated with adverse psychiatric symptoms?

A
  • benzodiazepines
  • leviteracetam
  • barbiturates
  • topiramate
  • vigabatrin
  • zonisamide
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9
Q

What are the most common adverse events associated with leviteracetam?

A
  • hallucinations
  • delusions
  • aggressive behaviour
  • agitation
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10
Q

What are favourable effects associated with anti seizure medications?

A
  • mood stabilising effects
  • antidepressant effects
  • anxiolytic effects
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11
Q

Mood stabilising effects are associated with which anti seizure medications?

A
  • valporic acid
  • carbamazepine
  • oxcarbazepine
  • lamotrigine
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12
Q

Antidepressant effects are associated with which anti seizure medication?

A

Lamotrigine

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13
Q

Anxiolytic effects are associated with which anti seizure medications?

A
  • pregabalin
  • gapapentin
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14
Q

Withdrawal from anti seizure medications may lead to what?

A

Re-emergence of pre-existing mood/ anxiety disorders

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15
Q

Epilepsy surgery is associated with

adverse effects

A
  • recurrence of pre-exisiting psychiatric disorder
  • exacerbation of pre-existing psychiatric disorder
  • de novo psychopathology
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16
Q

What is the relationship between pre-surgical psychiatric hx and seizure remission

A

People who have a pre-surgical hx have a lower rate of seizure remission

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17
Q

Post surgical depression is most common in which type of epilepsy surgery?

A

Temporal lobe resection

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18
Q

Lifetime depression hx is associated with which medication effects

A
  1. increased risk of refractory epilepsy
  2. increased risk of treatment resistance
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19
Q

Risk of mortality is higher or lower in people with epilepsy compared to the general population and unaffected siblings

A

Higher

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20
Q

True or False

There is a 32x increased risk of suicide in people with epilepsy with comorbid mood disorders

A

True

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21
Q

True or False

There is a 12x increased risk of suicide in people with epilepsy with comorbid shizophrenia and anxiety

A

True

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22
Q

Which factors are associated with undertreatment of psychiatric comorbidities in people with epilepsy

A
  • patients are reluctant to volunteer information about mood
  • neurologists aren’t trained enough in psychology
  • there is not enough time in clinic
  • there is not enough systematic data on treatment strategies
  • treatment is better the more experienced the clinician is
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23
Q

NDDI-E

A

Neurological Disorders Depression Inventory for Epilepsy

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24
Q

What is the most common psychiatric comorbidity in adults with epilepsy?

A

Depression

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25
Depression is most common in which epilepsy sub populations
- temporal lobe epilepsy - refractory epilepsy - neurological comorbidities - females
26
Better mood is associated with which two factors?
- males - lower anti seizure medication count
27
What are some feature of mood disorders in epilepsy compared to primary psychiatric conditions?
- mood disorders may not meet diagnostic criteria - symptoms may be becuase of adverse effects of ASMs - symptoms may be pre- or post-ictal - mood syndrome may be atypical (e.g., interictal dysphoric disorder)
28
What are common clinical features of of mood disorders in patients without a DSM dx?
- loss of interest/ pleasure - fatigue - anxiety - irritability - poor frustration tolerance - mood lability
29
What direction is the relationship between epilepsy and depression?
Bidirectional
30
# *True or false* Depression increased the risk of developing epilepsy *more* than epilepsy increases the risk of depression
True
31
What percentage of patients was psychosis reported in an epidemiological study in Iceland?
7.2%
32
In a Danish study by Dreier et al. (2019) what did they find increased the risk of psychiatric disorders? | *highest-lowest HR*
- hx of febrile seizures and epilepsy - epilepsy - hx of febrile seizures
33
What are the possible mechanisms for the bidrectional relationship between depression and epilepsy?
- structural abnormalities seen as hippocampal atrophy or increased/ decreased amygdala volume - monamine pathways - cerebral glucose metabalism - hypothalamic-pituitary-adrenal axis malfunction (HPA axis) - interleukin-1β - genetic factors (family hx of psych dis)
34
What are possible epilepsy related factors for the mechanisms underpinning depression in epilepsy?
- iatrogenic (adverse drug reactions, forced normalisation, post-surgical depression - poor seizure control - chronic stress
35
What is the forced normalisation paradox?
As a result of seizure control through medication, the patients' EEG normalises but psychiatric disturbances emerge or worsen.
36
37
What are the possible psychosocial factors underpinning depression in epilepsy?
* sadness * despair * low self-esteem * self-reproach * social isolation * stigma * social disability
38
Which anti seizure medications have adverse effects on mood?
- barbiturates - vigabatrin - zonasimide - topiramate - tiagabine - pregabalin
39
Which antiseizure medications have mood *stabilising* effects
- phenytoin - carbamazepine - valproate - lamotrigine - oxcarbazepine
40
Which antiseizure medications are recommended for epilepsy patients with comorbid anxiety?
- benzodiazepines - gabapentin - pregabalin
41
Which ASM is recommended for epilepsy patients with comorbid depression?
Lamotrigine
42
Why should tricyclic antidepressants be avoided to treat depression in epilepsy?
They may have proconvulsant effects (greater or increased seizure risk) above therapeutic plasma levels
43
What are two examples of tricylclic antidepressants?
- amitriptyline - nortriptyline
44
**FACT**
There is no evidence of increased seizure risk of tricyclic antidepressants at or below the therapeutic plasma levels
45
What did Gillam et al. (2019) find?
After 16 weeks of sertraline or CBT 52.8% and 60.3% of patients, respectively remitted from MDD. Despite no reports of a between group difference in the occurrence of generalised tonic clonic seizures
46
47
# *advantages of medication* SSRIs
Lower seizure incidence more compared to placebo
48
Why should clinicians be careful about prescribing SSRIs alongside antiseizure medications?
- interactions between SSRIs and ASMs - ASM toxicity (e.g. sertraline inhibits lamotrigine metabolism)
49
What are the ILAE guidelines for antidepressant use in epilepsy?
- start low and go slow - continue treatment for 6 months after recovery from the first depressive episode - continue treatment for 2 years after recovery from a second and subsequent depressive episode
50
Which two SSRIs can increase serum levels of ASMs?
Fluoxetine and fluvoxamine
51
What could happen if antiseizure medications are discontinued because of positive psychotropic effects?
Depressive symptoms may be provoked
52
How many days after a seizure can post ictal depression occur?
Up to 5 days
53
What is the median duration of post ictal depressive symptoms?
24 hours
54
How common is anxiety in people with epilepsy compared to the general population?
2-4 times
55
What are the risk factors for anxiety in epilepsy?
- epilepsy status (optimally controlled vs refractory) - epileptic focus - temporal lobe epilepsy - older age - later age of seizure onset
56
What is the treatment for panic disorder in PWE?
- SSRI and CBT in the acute phase - SSRI and CBT vs CBT alone for long term management - antidepressants and benzodiazepines
56
What is the treatment for GAD in epilepsy? | *generalised anxiety disorder*
- CBT - SSRI - SNRI - benzodiazepines - azapirones (e.g. busiprone) - antihistamines (e.g. hydroxyzine) - pregabalin (short- and longterm) - imipramine - venlafaxine - paroxetine
57
What is the treatment for social anxiety disorder in epilepsy?
- SSRI first line treatment (sertraline, paroxetine) - reversible inhibitors of monoamine oxidase A (RIMAs) - benzodizepines - gabapentin
58
What is the treatment for OCD?
- CBT (mild to moderate OCD) - antidepressants (severe or when CBT is ineffective)
59
How are peri-ictal changes managed pharmacologically?
- manage the prodome - psychoeducation - optimise antiseizure treatment (in turn abolising prodromes) - regularly review treatment
59
60
What is Sucksdorff et al. (2015) find? | *bipolar disorder*
- bipolar disorder is associated with comorbid epilepsy - incresaed risk of bipolar disorder in epilepsy is not associated with parental epilepsy - OR 2.53
61
What are serious adverse effects of antidepressants?
Antidepressants can cause manic and hypomanic episodes and induce rapid cycling.
62
Antiseizure medications, namely sodium valproate and lomtrigine, can be used for what other purpose...
mood stabilising
63
Which two anti seizure medications can be used to treat unstable and rapid cycling forms of *bipolar disorder*
Carbamazepine and sodium valproate
64
Lamotrigine
Lamotrigine is particularly effective in depressed phase and long-term maintenance.
65
Prevalence of psychosis in epilepsy
4 to 5 %
66
Which antiseizure medications are associated with iatrogenic psychosis?
- ethosuximide - **topiramate** - vigabatrin - zonisamide - levetiracetam | 3.7% of patients develop psychosis in one study using topiramate
67
What are the risk factors for iatrogenic psychosis?
- high initial dose of antiseizure medications - rapid titration schedule - patients with past psychiatric history - patients with severe epilepsy - patients with high seizure frequency
67
What is the pathophysiology of psychosis in epilepsy?
- microdeletion in genomic area 15q-13-14 which is associated with the development of schizophrenia or juvenile epilepsy - LGI1 in autosomal dominant partial epilepsy with auditory features may play a role in regulating glutaminergin synaptic transmission - ion channelopathies - variation in CACNA1C gene *the pathophysiology is similar to that in schizophrenia*
68
Which psychiatric disorders are associated with a a variation in the CANA1C gene?
- schizophrenia - bipolar disorder - depression - epilepsy
69
When do post- and interical psychosis usually occur?
After a cluster of secondary generalised tonic clonic seizures in temporal lobe epilepsy
70
How long do psychotic episodes typically last?
1 to 6 days
71
When do psychotic episodes remit?
Spontaneously within days to weeks
72
What are the characteristic features of post- and interictal psychosis?
- mixed mood - paranoid delusions with religious content - increased self harm risk
73
How do you treat psychosis in epilepsy?
Treat the seizures!
74
When does interictal psychosis typically develop?
After several years of active mesial temporal lobe epilepsy
75
Treatment considerations
- interactions - proconvulsant effects - individualised treatment - side effects
76
What type of antipsychotic is clozapine?
An enzyme inducing neuroleptic
77
What are the contraindications for clozapine?
- Reduced plasma levels of ASMs - bone marrow suppression
78
Clozapine and which antiepileptic increase bone marrow suppression?
Carbamezapine
79
What are two common side effects of antipsychotics?
Weight gain and sedation
80
What is the risk associated with prescribing antipsychotics and ASMs on weight gain and sedation?
Increase
81
Which three ASMs increase the risks associated with antipsychotics?
- sodium valproate - carbamezapine - barbiturates
82
Which antipsychotic (C) may have pro convulsant effects?
Clozapine
83
How is clozapine thought to increase seizures
- it may induce epileptiform discharges in EEG - it may induce seizures even in the therapeutic range
84
What do proconvulsant effects of antipsychotics depend on?
Dose and titration
85
What class of antipsychotics are better tolerated in epilepsy?
Atypical antipsychotics
86
Name three atypical antipsychotics
Risperidone Olanzapine Quetiapine
87
What is the relationship between clozapine dose, plasma level and EEG?
There is a strong relationship between clozapine dose and plasma level and the occurence of clozapine-induced EEG abnormalities
88
Clozapine is widely used in which type of schizophrenia?
Refractory (treatment resistant)
89
What is an important adverse effect of clozapine?
Seizures
90
Whihch drug is typically used as a clozapine-induced seizure phropylactic?
Valproate

Neuropsychiatric disorders (30 decks)

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