A PPT ON BASIC CLASSIFICTION OF EPILEPSY AND PSYCHIATRIC ASPECTS

1. CLASSIFICATION AND
PSYCHIATRIC
PRESENTATIONS OF
EPILEPSY
DR. JITHIN T JOSEPH
Chair : Dr. ANIJI V R

2. OUTLINE
1. Prevalence
2. Etiology
3. Terminology
4. Classification of seizure
5. Epilepsy syndromes
6. Psychiatric presentations
7. Conclusions

3. PREVALENCE IN CHILDHOOD
• 75% with onset before age of 20 years
• Prevalence:
4.1/1000 in children up to 11 years old(National
Child Development study,1983);
4.71/1000 in children up to 19 years old(Oklahoma
study,1989)
• Incidence: 49/100,000 population

4. ETIOLOGY
Febrile
• Febrile convulsion
• Convulsion with fever
• Intracranial infection
Non-febrile
• Metabolic disturbance
• Trauma
• Poisons / toxins / recreational drugs
• Cerebral dysgenesis / malformation
• Cerebral damage / cerebral tumor
• Neurocutaneous syndromes

5. TERMINOLOGY
• Seizure—transient involuntary alteration of consciousness, behavior,
motor activity, sensation and/or autonomic function due to abnormal
discharge of cortical neurons; an episodic event, may have provoking
factors, e.g. anoxia, alcohol, drugs
• Convulsion– seizure with prominent alteration of motor activity
• Epilepsy—a disorder with recurrent seizures(2 or more), unprovoked by
a specific event such as fever, trauma, infection, or chemical change,
stereotypic
• Aura—a component of seizure which occurs before consciousness is lost
and for which memory is retained afterwards; it localizes attack to the
point of origin in the CNS
• Automatisms--coordinated adapted involuntary motor activity occurring
during the state of clouding of consciousness; usually followed by
amnesia of the event

6. •Tonic seizure: excessive motor outflow, giving rise
to a tetanic state of the muscles involved.
•Atonic seizure: muscle tone drops to a very low
values resulting in a sudden fall of the body
•Clonic seizure: a tonic seizure with periodic
interruptions
•Tonic-clonic seizure: starts as a generalized tonic
seizure and then interrupted during clonic phase
and ending in complete relaxation.
•Myoclonic seizure: short involuntary contraction of
one or more muscles (local or generalized)

7. CLASSIFICATION OF SEIZURE
Seizures
Partial Generalized
Simple Complex Partial with
secondary
generalization
Absence seizures
Myoclonic seizures
Clonic seizures
Tonic seizures
Tonic-clonic seizures
Atonic seizures
* ILAE classification of seizures 1981

11. Partial vs Generalized
•Partial: if only one hemisphere is
involved
Simple—no impairment of consciousness, features depend on the region of the
brain that is affected
Complex—consciousness impaired, may have automatisms e.g. chewing,
wandering off, dressing, undressing
•Generalized: most or both hemispheres
are involved, loss of consciousness

12. Simple Partial Seizures
• Preserved consciousness (“aura”)
• Symptoms related to involved brain region
• Frontal lobe: movement, thought, speech
• Temporal lobe: memory, speech, smell, taste, abdominal sensations
• Parietal lobe: body sensations
• Occipital lobe: vision

13. Complex Partial Seizures
• Altered consciousness
• Unresponsive or less responsive, staring
• Impaired memory after seizure
-Automatisms: hand and mouth movements (lip smacking, grabbing)
• Hypermotor: wild flailing movements (frontal)

14. Generalized Seizures
•Most have abnormal, unnatural movements
• Tonic (stiffening)
• Clonic (repetitive jerking)
• Tonic-clonic (“grand mal”)
• Atonic (limp)
• Myoclonic (irregular jerking, may retain awareness)
• Atonic (falling suddenly)
•Absence (“petit mal”): staring, may blink, arrest of
activity

15. Epilepsy syndrome
Epilepsy syndromes may be classified
according to:
 Whether the associated seizures are partial or
generalized
 Whether the etiology is idiopathic or symptomatic/
cryptogenic
 Several important pediatric syndromes can further be
grouped according to age of onset and prognosis
EEG is helpful in making the diagnosis
Children with particular syndromes show signs
of slow development and learning difficulties
from an early age

16. 1 Localisation-related (local, focal, partial)
epilepsies and
syndromes
• 1.1 Idiopathic
• Benign childhood epilepsy with centrotemporal spikes
• Childhood epilepsy with occipital paroxysms
• Primary reading epilepsy
• 1.2 Symptomatic
• Chronic epilepsia partialis continua of childhood (Kojewnikoff’s
• syndrome)
• Syndromes characterised by seizures with specific modes of
• precipitation
• Temporal lobe epilepsy
• Frontal lobe epilepsy
• Parietal lobe epilepsy
• Occipital lobe epilepsy
• 1.3 Cryptogenic

17. 2 Generalised epilepsies and
syndromes
• 2.1 Idiopathic (with age-related onset)
• Benign neonatal familial convulsions*
• Benign neonatal convulsions*
• Benign myoclonic epilepsy in infancy*
• Juvenile absence epilepsy (pyknoepilepsy)
• Childhood absence epilepsy
• Juvenile myoclonic epilepsy (impulsive petit mal)
• Epilepsy with grand mal seizures on awakening
• Other generalised idiopathic epilepsies
• Epilepsies with seizures precipitated by specific modes of activation

18. • 2.2 Cryptogenic or symptomatic
• West syndrome
• Lennox–Gastaut syndrome
• Epilepsy with myoclonic–astatic seizures
• Epilepsy with myoclonic absences
• 2.3 Symptomatic
• 2.3.1 Non-specific etiology
• Early myoclonic encephalopathy*
• Early infantile epileptic encephalopathy with suppression-burst*
• Other symptomatic generalised epilepsies not defined above
• 2.3.2 Specific syndromes
• Epileptic seizures complicating other disease states

19. • 3 Epilepsies and syndromes undetermined, whether focal
• or generalised
• 4 Special syndromes
• 4.1 Situation-related seizures
• Febrile convulsions
• Isolated seizures or isolated status epilepticus
• Seizures occurring only when there is an acute metabolic or toxic
• event due to factors such as alcohol, drugs, eclampsia, non-ketotic
• hyperglycaemia

20. G40 Epilepsy
G40.0 Localization-related idiopathic epilepsy and epileptic syndromes with seizure of localized onset
G40.1 Localization-related symptomatic epilepsy and epileptic syndromes with simple partial seizures
G40.2 Localization-related symptomatic epilepsy and epileptic syndromes with complex partial seizures
G40.3 Generalized idiopathic epilepsy and epileptic syndromes
G40.4 Other generalized epilepsy and epileptic syndromes
G40.5 Special epileptic syndromes
G40.6 Grand mal seizures, unspecified
G40.7 Petit mal, unspecified, without grand mal seizures
G40.8 Other epilepsy
G40.9 Epilepsy, unspecified (includes: epileptic convulsions, fits [sic], or seizures)
G41 Status epilepticus
ICD 11
ICD 10 CLASSIFICATION

21. Infantile spasms (West syndrome)
• Onset: between 4 and 6 months of age
• ‘salaam spasms’
• Flexor spasms last 1-2 s and are often multiple, occurring in
bursts of 20-30 spasms, frequently on waking
• Infants will have developmental delay and later learning
disability or epilepsy.
• Treatment: vigabatrin or corticosteroids.

22. Lennox-Gastaut Syndrome
• Affects children of 2-5 years old
• Multiple presentation of seizures
• Later, neuro-developmental arrest or regression and
behaviour disorder
• Treatment: Sodium valproate
• Poor prognosis

23. Childhood Absence Epilepsy
•Onset at 3-12 years
• Peak at 6-7 years
• Second peak at 11-12 years
•Females more than males
•Family history in 15-44%
•Rarely associated with developmental
problems.
•Can be induced by hyperventilation.

24. •Treatment: Sodium valproate
•Good prognosis with 95% remission in adolescence.
•Risk of generalized TC seizures is 30-40%(increased
risk if begin after the age of 8 years)

25. Juvenile Myoclonic Epilepsy (JME)
• Autosomal dominance with variable penetrance
• A common cause of tonic-clonic seizures in teenagers and
young adults(myoclonus paricularly in morning)
• Myoclonic seizures precede tonic-clonic seizures by 2-3 years;
tonic-clonic seizures typically occur when patient reaches 10-
17 years
• Prognosis excellent but requires lifelong treatment

26. Benign Rolandic Epilepsy
• Most common partial epilepsy
• Onset 2-12 years
• M:F 1.5:1
• Usually occuring in sleep-wake transition states
• 10-13% have a single seizure
• 20% have frequent seizures
• 65% nocturnal
• 15% nocturnal or diurnal
• 10-20% waking state only

27. • Typical presentation:
• On waking, fully conscious, mouth to one side, salivating and focal
twitching of one side of the face
• Duration 1-2 mins;
• Child may recall a sensation of numbness, pins and needles or
“electricity” in the tongue, gums or cheeks;
- Remains conscious but aphasic post-ictally
- Secondary generalization may be seen
- Remits spontaneously in adolescence; no sequelae
- No medication if infrequent seizures.

28. PSYCHIATRIC
PRESENTATIONS IN EPILEPSY

30. • Most patients with epilepsy do not suffer from psychiatric problems
• Patients with severe epilepsy are at increased risk of psychiatric problems
• Studies among epileptic patients showed that there is 30-50 % increased
prevalence of psychiatric symptoms among them.
• Population survey
• Children : > 3-fold increased psychiatric morbidity in epilepsy (Graham&Rutter,
1968)
• GP- surveys:-
• 30 - 50% significant psychiatric morbidity
• Lower prevalence in seizure-free patients (Jacoby, 1996; O’Donoghue, 1999)

31. Why this increased prevalence?
Same underlying pathology responsible for epilepsy and psychiatric
disorder.
Seizures produce pathogenic electrical / biochemical changes.
 Effects of treatment.
Psychosocial correlates of epilepsy (disability/ stigma / family
background

32. Any risk factors ?
• Intractable epilepsy
• Associated brain damage
• Temporal lobe epilepsy
• Early onset epilepsy
• Perceived seizure severity
• Social handicap
• Adverse family background

33. Psychiatric presentations in epilepsy :-
• Related to underlying cause of the epilepsy
• Related to seizures
• Pre-ictal
• Ictal
• Post-ictal
• Inter–ictal disorders
• Non-epileptic (dissociative) seizures

34. Disorders clearly attributable to the brain
disorder causing epilepsy
• Learning disability
• Specific epileptic syndromes
1.West syndrome
2.Lennox–Gastaut syndrome
3.Epilepsy with continuous spike-and-wave during slow-wave sleep
4.Progressive myoclonic epilepsies
• Cognitive and behavioural manifestations of other acquired causes of
epilepsy

35. Disorders strictly related in time to seizure
occurrence
• PRE-ICTAL
• ICTAL: psychiatric manifestations of seizure activity
1.Aura
2.Automatisms
3.Non-convulsive status epilepticus
• POSTICTAL
1.Delirium
2.Psychosis

36. Interictal psychiatric disorders
• Affective disorder
• Schizophrenia-like psychosis
• Personality disorder/behaviour disorder
• Dementia
• Dissociative seizures

37. Disorders clearly attributable to the brain
disorder causing epilepsy
• Include patients who have epilepsy of known aetiology in whom the
underlying brain pathology is itself associated with psychiatric,
cognitive or behavioural manifestations.
• The neurobehavioral manifestations are judged to be a consequence
primarily of the underlying brain disorder rather than of epilepsy

38. Disorders clearly attributable to the brain
disorder causing epilepsy
• Learning disability
• Specific epileptic syndromes
1.West syndrome
2.Lennox–Gastaut syndrome
3.Epilepsy with continuous spike-and-wave during slow-wave sleep
4.Progressive myoclonic epilepsies
• Cognitive and behavioural manifestations of other acquired causes of
Epilepsy like dementia and brain tumours

39. PRE-ICTAL DISORDERS
• INCLUDE THE PRE ICTAL PRODROME
The term ‘prodrome’ refers to a variety of subjective symptoms
occurring in the hours or even days leading up to a seizure.
They herald seizure onset but do not form part of it
Should be distinguished from aura of partial seizures ( gradual onset
and prolonged duration)
Seen in upto 20 % patients and more common in localised epilepsy
Poorly understood pathophysiology

40. • SYMPTOMS INCLUDE
• Non-specific, Illdefined Feelings Of Malaise
• Headache,
• Tiredness,
• Irritability
• Dysphoria
• There may be more pronounced affective symptoms, in particular
depression.

41. ICTAL:
• psychiatric manifestations of seizure activity
1.Aura
2.Automatisms
3.Non-convulsive status epilepticus

42. Epileptic aura
• Epigastric aura - 30–53%
• Cephalic aura - 23–30
• Anxiety/fear - 14–24
• Hallucinations/illusions
• Visual -16–18
1.Elementary 5–7
2.Complex 3
• Auditory - 8–16
1.Elementary 1–12
2.Complex 3–4
• Olfactory - 8–12
• Gustatory - 3–11
• Somatosensory - 2–19
• Dysmnesic/déjà vu - 7–18
• No aura 10–51

43. • Usually psychotic symptoms arises in temporal lobe seizures
• They are not psychiatric disorders
• It may create diagnostic confusion , so clear distinction is needed
• In a simple partial seizure such ictal psychiatric phenomena may be
the only manifestation of the seizure.
• While in complex partial seizures they constitute the aura that
precedes clouding of consciousness and loss of awareness.

44. How to distinguish it from real
psychiatric symptoms ?
• These are brief, paroxysmal and highly stereotyped
• A clear history can help to easily distinguish the symptoms
• Presence of other epileptic phenomenon in history
• Information from observer -motor features such as subtle dystonic
posturing and automatisms, can go un noticed by patient if
consciousness is impaired.
• Subjective feeling of the patient should be considered

45. ICTAL ANXIETY VS PANIC DISORDER
The autochthonous nature of ictal fear which arises ‘of itself’,
independent of situational triggers
The intense and unique quality of the emotion, which is typically
quite distinct from the patient’s experience of ‘normal’ anxiety
The cognitive symptoms of panic, such as a fear of dying or of
suffocation, are usually absent in ictal fear.

46. Epileptic automatisms
• ILAE definition which states that an automatism is ‘a more or less
coordinated, repetitive motor activity usually occurring when
cognition is impaired and for which the subject is usually amnesic
afterwards.
• Automatisms have conventionally been regarded as the behavioural
concomitants of ictal or postictal delirium.
• But recently oro facial automatisms have now been documented
during simple partial seizures in patients who show no evidence of
clouding of consciousness.
• The great majority of automatisms are brief, lasting from a few
seconds to several minutes.
• Occasional examples have lasted for up to 1 hour.

47. • These may be relatively self-contained and stereotyped, or be
influenced by environmental factors.
• The subject may merely continue with what he was doing, a dazed
expression and sudden inaccessibility being the only indications of
the seizure.
• Brief automatisms can in fact pass unnoticed by onlookers.
• To the onlooker, in the great majority of automatisms, the subjects
are clearly out of touch with their surroundings.
• Typically they look somewhat dazed and vacant, and often anxious
and tense.

48. Non-convulsive status epilepticus
• Non-convulsive status epilepticus is a term used to denote conditions
in which prolonged electrographic seizure activity results in non-
convulsive seizure symptoms.
• Most common forms are complex partial status and absence status.
• Mental state abnormalities and behavioural disturbance may be the
most conspicuous features.
• Often mistaken for psychiatric disorders

49. Psychiatric presentations in complex
partial status
• Complex partial status is the most common form of non-convulsive
status.
• It usually arises in a patient known to have epilepsy or in the context
of an acute cerebral insult.
• The classical picture is one of fluctuating delirium with motor
automatisms.
• Behavioural changes range from psychomotor retardation to states
of marked agitation and affective disturbance.
• The usual picture, however, is of a patient who seems relatively
composed but withdrawn and inaccessible.

50. Symptoms includes
• Sluggish, Restless, Repetitive And Disorganised Speech and
Behaviour.
• Anxiety is the most common affective change and may be intense,
accompanied by severe agitation.
• There may be psychotic symptoms including visual or auditory
hallucinations and paranoid ideation
• A clinical picture resembling catatonia has been described

51. Simple partial status
• Commonly involves focal motor seizures in the syndrome epilepsia
partialis continua
• Anxiety is the manifestation of simple partial status which is
commonly reported.
• Since the consciousness is clear , this may create diagnostic
confusion.
• Musical hallucinations has also been reported.

52. Absence status
• Absence status is a prolonged state of impaired consciousness
associated with continuous 3-Hz spike-and-wave EEG abnormality.
• It is usually seen in a child or adolescent known to have generalised
epilepsy.
• Clinical features may be so subtle and sometimes may go unnoticed
• During the episode subject is confused, uncoordinated, slowed and
perseverative.
• Can present as simple as slowing of ideation and expression
• But more commonly there is marked disorientation, confusion and
automatic behaviour.
• The patient may be virtually stuporose, remaining motionless and
apathetic

53. • POSTICTAL
1.Delirium
2.Psychosis

54. Post ictal delirium
• This is the altered state of consciousness following an epilepsy
• The onset of seizure is abrupt , but regaining of consciousness is
gradual.
• To an observer it will seem like a person who is arousing from sleep.
• Recovery is more prolonged in
1.Temporal lobe epilepsy
2.In GTCS

55. • Even after recovery they may complain of headache, drowsiness and
mental slowing.
• Recovery is more prolonged in elderly and in patients with ID.
• In such cases distinction between delirium and non convulsive status
may be difficult
• Careful observation for motor signs is important and an EEG will
usually clarify the diagnosis.

56. Postictal Psychosis
• The term ‘postictal psychosis’ refers to brief self-limiting episodes of
psychosis that are of abrupt onset and follow seizures.
• Postictal psychosis is probably the most common psychotic disorder
seen in epilepsy- 6%
• CLINICAL FEATURES
• Most patient had TLE, but it can also follow other localised ,or
generalised epilepsy.
• Most had a seizure duration of over 10 years.
• Precipitated by an exacerbation of seizure ,may be complex partial or
generalised .

57. • Followed by a lucid interval which can last upto 24 hours.
• During this period the person is fully conscious and aware.
• The onset of psychotic symptoms is then often sudden and dramatic
accompanied by marked agitation and behavioural disturbance.
• Presentation is pleomorphic with a mixed picture including
• Paranoid , grandiose and religious delusions.
• Auditory , visual and somatic hallucinations.
• Prominent variable affective changes

58. • Consciousness is clear during these symptoms.
• A representative estimate of the mean duration of the psychotic
episode is 3.5 days, with a range from 16 hours to 18 days.
• EEG obtained during an episode of postictal psychosis may show
diffuse background slowing or an increase in inter ictsl epileptifom
abnormalities.
• In clinical practice, postictal psychosis must be differentiated from
non-convulsive status.(impaired consciousness and lucid interval,
eeg)

59. Risk factors
• Family history of affective disorder.
• More frequent seizure clustering and secondary generalisation.
• TLE with bilateral temporal lobe abnormality in EEG
• Aetiologies that are associated with diffuse damage such as
encephalitis and head injury.

60. Management
• Self limiting condition , so no antipsychotic is needed
• But to control agitation and behavioural abnormality admission ,
close observation and sedation may require.
• Chance of recurrence is there
• Between 14% and 20% of patients with postictal psychosis will
eventually develop chronic inter-ictal psychoses, often after several
years and recurrent episodes.
• Main focus of treatment should be improved seizure control.
• Role of antipsychotic prophylaxis ? No evidence to support
• Role of surgery?

61. Interictal psychiatric disorders
• Affective disorder
• Schizophrenia-like psychosis
• Personality disorder/behaviour disorder
• Dissociative seizures

62. Depression
• Depression and anxiety are the most frequently encountered
interictal psychiatric disorders in epilepsy.
• The prevalence of depression in epilepsy – studies had shown
different results
• Prevalence of major depression has been estimated as 17–21%
(Brookes & Crawford 2002; Jones et al. 2005)

63. Clinical presentation of depression in
epilepsy
• Atypical presentations
• Most of the time fall short of diagnostic criteria ,yet associated with a
higher morbidity.
• The terms ‘interictal dysphoric disorder’ (Blumer 1991) and
‘dysthymia-like disorder of epilepsy’ (Kanner 2003) have been
proposed to describe these presentations.
• The clinical picture is one of chronic dysthymia which is interrupted
at frequent intervals by brief periods of normal mood.
• Affective symptoms are pleomorphic, with prominent irritability and
endogenous somatic symptoms.

64. • Blumer (1991) has described a more elaborate complex of symptoms
Labile depressive symptoms (depressed mood, with somatic
symptoms including anergia, insomnia and pain)
Affective symptoms (anxiety and phobias)
Specific symptoms’ ( paroxysmal irritability and brief episodes of
euphoric mood.)
• The syndrome is said to respond to antidepressant treatment
perhaps in combination with low-dose neuroleptics
• The atypical nature of these presentations is cited as one reason why
depression in epilepsy often goes unrecognised and untreated

65. Risk factors for depression
• Practical consequences of disability, including unemployment,
dependence, social limitations and driving restrictions, and stigma .
• On going seizure activity - Jacoby et al. (1996) no seizure (53-4), one
seizure (27-11) ,more frequent seizure (20-21)
• TLE has more chance of depression – no laterality
• A family history of psychiatric illness was found in 50% of patients
with epilepsy and depression by Robertson et al.
• AED -Those most frequently implicated include levetiracetam,
tiagabine, topiramate and vigabatrin – but no conclusive evidence

66. Anxiety
• Almost similar prevalence as that of depression . Can co exist with
depression.
• But its not well studied.
• Ongoing seizure activity is considered as a risk factor
• Frequent presentations are agoraphobia, generalised anxiety
disorder and social phobia
• Agoraphobia may present as fear to go out in pubic due to fear of
seizure

67. • The term ‘seizure phobia’ is sometimes used to refer to the situation
in which a patient’s fear of having a seizure .
• It is more disabling than the seizures themselves.
• The fear may be one of injury or embarrassment and is
disproportionate to objective risk.
• Benzodiazepines miss use and dependence may be seen

68. Schizophrenia-like psychosis
• These symptoms can make a diagnosis of schizophrenia alone in
absence of the epilepsy.
• It is reasonable to conclude that epilepsy is indeed associated with
an increased risk of schizophrenia.( Mendez et al-1993; Stefansson et
al 1988).
• Evidence for this association is most robust for patients who have
chronic epilepsy associated with significant disability or requiring
specialist medical attention

69. Nature of the psychosis
• Slater et al. (1963)
• The mean age of onset of schizophrenia was 30.
• The symptoms developed after a mean duration of 15 years
• All the cardinal symptoms of schizophrenia were exhibited
Subtle difference noted
• Personality abnormalities before the onset of psychosis were not
prominent.
• Catatonic phenomena were rare and the loss of affective response
did not occur so early or become so marked as in primary
schizophrenia.
• Patients were more friendly and more open towards the medical
team

70. Risk factors
• Age of onset of seizure- risk of psychosis increased linearly with
increasing age( Quin et al 2005)
• Association between localisation related epilepsy - TLE
• Organic insult to brain
• Low IQ
• Mesial temporal sclerosis
• No relationship with family history

71. Aetiology
1. Chance association
2. Genetic predisposition – history of epilepsy can be a risk factor for
developing psychosis
3. Disability due to epilepsy – may play a role , but alone not
significant .
4. Organic pathology
5. AED medications.

72. Personality in epilepsy
• From their study among patients with TLE they formed a 18-trait
Bear and Fedio Index (BFI)
• They observed that some traits are particularly seen in patients
with TLE compared to the control group(patients with NMD)
• The following traits showed significant difference humourlessness,
circumstantiality, dependence, sense of personal destiny and
preoccupation with philosophical concerns.
• They also observed that there is difference in these traits
depending on the site of seizure origin.
72

73. • Emotionality
• Mania
• Depression
• Guilt
• Humorlessness
• Altered sexual interest
• Aggression
• Anger and hostility
• Hypergraphia (excessive
writing)
• Religiosity
73
• Philosophical interest
• Sense of personal
destiny
• Hypermoralism
• Dependency
• Paranoia
• Obsessionalism
• Circumstantiality
• Viscosity
• BFI

74. Epilepsy and sexual dysfunction
• Men – reduced libido ,erectile dysfunction(57%)
• Women – hypo sexuality is rare, abnormalities of arousal and
orgasmic dysfunction are relatively common .
• May not be as a direct result of epilepsy, usually psycho social
• Impact of recurrent seizure on confidence, self-esteem, social activity
and interpersonal relationships
• Fear of seizure attack during sex

75. • Some problems have an organic basis
• AED can change the level of sex hormones
• Hepatic enzymes inducers (most notably phenobarbital, phenytoin
and carbamazepine) increase circulating sex hormone-binding
globulin.
• Free testosterone level decreases
• Drugs like lamotrigine have no such effect
• Patients with right temporal lobe foci have more prevalence
• Involvement of the limbic system may be the reason

76. Crime and epilepsy
• Earlier researchers postulated that epilepsy is associated with an
increased risk of criminal behaviour .
• This had lead to stigma and other social problems
• But later , detailed studies among prisoners disproved this concept.
• There is some studies which showed increased prevalence of
epilepsy in prisoners.
• But the increase in crime may be attributed to co morbid psychiatric
illness than epilepsy

77. • Few incidents had happened when the patient had automatisms
• This is of medico legal importance
• In legal terms, an automatism occurs if an act is committed but was
neither intended nor the result of recklessness(i.e.there is actus rea
but no mens rea)
• Indian scenario ?

78. Cognitive function in epilepsy
• There is good evidence to support that at least a group of people
with epilepsy had some sort of cognitive problems.
• Such cognitive deficits are present at the time epilepsy is first
diagnosed and may even precede the onset of seizures.
• This is explained by the organic brain pathology in epilepsy
• Cognitive deficits can also be present after the onset of seizure.
• Hermann et al. (2006) compared 53 children with epilepsy with 50
healthy controls (age- and gender matched first cousins of the
patients).
• Of the children with epilepsy, 26%had a history of academic
problems (compared with 4% of controls)

79. Dissociative seizures
• Dissociation can be thought of as a psychologically mediated, altered
state of awareness or control over neurological function.
• In ICD-10, the term ‘dissociative convulsions’ is used to refer to
paroxysmal episodes of behaviour that resemble epileptic seizures
and which are believed to be due to unconscious psychological
processes.
• Has to be differentiated from fictitious disorder and malingering .
• Fictitious disorder represents a willful, conscious attempt to simulate
illness for reasons that are understandable in terms of the
individual’s psychological state.
• In malingering illness is simulated to have some physical gain.

80. • EVIDENCE IN FAVOUR OF DISSOCIATIVE DISORDER , BEING
UNCONSCIOUS
Most patients are compliant with antiepileptic drugs before the
correct diagnosis is made.
When patients are admitted for telemetry, the majority have a
seizure in a setting which they must surely recognise involves
sophisticated monitoring.
The seizures are usually a poor imitation of epilepsy.

81. Demographic features
• As common as 1/5th
of the patients being referred for evaluation of
epilepsy.
• Over two-thirds of patients are female.
• Seizures typically begin in the late teens or early twenties.
• Often left undiagnosed for many years – may take AEDs
• Differentiation from true epilepsy is needed

82. Predisposing, precipitating and
maintaining factors in dissociative
seizures.
Biological Psychological Social
Predisposing factors 1. Learning difficulties
2. Genetic influence on
personality
3. Biological effect of
early adversity on CNS
development
1. Somatising trait
2. Dissociative trait
3. Avoidant coping style
4. Personality disorder
5. Mood disorder
1. Adverse (abusive)
experiences in childhood
2. Poor family functioning
3. Traumatic experiences in
adulthood
4. Modelling of attacks on
others with epilepsy
Precipitating factors 1. Perception of life events as
negative/unexpected
2. Acute panic attack/syncope
Adverse life events
Maintaining factors 1. Perception of symptoms as being
beyond personal control/due to
disease
2. Agoraphobia: avoidant and
safety behaviour
3. Angry/confused/anxious
reaction to diagnosis
1. Angry/confused/anxious
reaction of carers to the
illness and to medical
encounters
2. Fear of responsibilities of
being well/benefits of
being ill

83. HOW TO DIFFERENTIATE ?
• Stereotyped attacks -Common
• Incontinence - Occasional
• Injury
1.Biting inside of mouth Occasional
2.Severe tongue-biting Very rare
• Nocturnal occurrence (‘in sleep’)

84. DIFFERENCES …
Features Dissociative seizure True epilepsy
Duration over 2 minutes Common Rare
Motor features - Gradual onset Common Rare
Fluctuating course Common very Rare
Eyes closed Common Rare
Thrashing, violent movements Common Rare
Side-to-side head movement
Common Rare
Asynchronous clonic movements Common Rare
Automatisms Rare Common
Weeping Occasional Very rare
Recall for period of unresponsiveness Common Very rare

85. CONCLUSION
• BASIC CLASSIFICATION – ILAE 1981/2017
• EPILEPTIC SYNDROMES
• PSYCHIATIRC PRESENTATION
Peri Ictal
Post Ictal
Inter Ictal
Dissociative Seizures

86. References
1. Leishman organic psychiatry
2. Epilepsy.com
3. ILAE website
4. Internet resources

87. THANK YOU