Clermont-Ferrand – « There is a bidirectional relationship between depression and epilepsy, with sometimes common alterations of neurotransmission and hyperactivity of the stress system “Commented the Dr Marie Arthuis (Psychiatrist, Marseille) during French -language neurology days (JNLF). Depression would therefore not be the simple consequence of a chronic disease. Moreover, on the epidemiological level, its prevalence in this context is higher than for other chronic diseases, including neurological: it would thus affect up to 30 % of patients and even up to 60 % of those with a pharmacoreist form. The occurrence of depression in an epileptic subject would be mainly linked to the limitation of activities, lack of social support or neurosensory or memory involvement of epilepsy, rather than severity or frequency of crises. Its impact on quality of life, response or tolerance to treatment and risk of ideation or suicidal act requires diagnosis and management. “” Also, it is essential to systematically question patients about the existence of an altered humor or a loss of interest over the last 2 weeks ». The Nddie questionnaire (Neurological Disorders Depression Inventory for Epilepsy), fast and specific, driving this location. It should be noted that in practice, the depressive symptoms fluctuate with the temporality of crises: we often observe a pre -ictal and inter-cultural dysphoria and an ictal and post-scatal depressive syndrome.
The first step is to optimize antiepileptic treatment and, in some cases, adapt the choice of the molecule certain antiepileptics (levatiracetam, topiramate, zonisamide, vigabatrin) have a deleterious influence on mood, unlike others (lamotrigine, carbamazepine, valproate). Adapting these prescriptions improves depressive symptoms before even considering the prescription of an antidepressant. Then, the care is based first on non -drug approaches: psychosocial support (work, family, etc.), therapeutic education, psychocorporeal approaches (yoga, full -conscious meditation relaxation) “ Even if they can be unsuitable when the patient is in full psychiatric decompensation », Support groups, regular moderate physical activity, psychotherapy. An antidepressant (ISRS in first intention, then Irsna or Mirtazapine if sleep disorder) can be prescribed if necessary. The use of the psychiatrist and/or the psychologist must be envisaged according to the severity of the troubles or the presence of other psychiatric comorbidities.
The case of psychoses
Psychoses also have a bidirectional relationship with epilepsy. Three simple questions make it possible to open the debate and evoke the existence of psychiatric disorders, especially psychotic, because ” Patients never think of evoking psychiatric history when they are asked about their medical history “Said the Dr Alexis Tarrada (Psychiatrist, Laxou) : has he seen a psychiatrist? Taken a psychotropic treatment? been hospitalized in psychiatry? These questions are also worth concern about family history.
Psychosis is mentioned before positive symptoms (delusional ideas, hallucinations, etc.), disorganization (affective, motor, cognitive, etc.) and negative symptoms (social withdrawal, alogy, etc.). “” In epilepsy, hallucinations are most often sensory during crises, and hallucinations are often intercritical. To orient the diagnosis, the temporality of psychotic manifestations is important (pre-: ictals and post-vestal and inter-scales). Peri -ictive disorders have a clear chronological link while inter-scales have no chronological link with crises: in this case, the etiological diagnosis is more complex, because these disorders can then be linked to epilepsy, be iatrogenic, or even be non-specific to epilepsy. “” It should not be forgotten that psychotic disorders can be pharmaco-induced or even linked to forced standardization, that is to say certain cases where the treatment initiated is quickly very effective ».
This diagnostic work should make it possible to distinguish psychoses specific to epilepsy, which are often associated with severe, old or pharmacoreisting forms, non-specific psychoses of epilepsy (according to DSM-5): often, these are linked to personal history, occasionally occur in personal history, in patients who often have preexisting psychiatric vulnerability.
In specific forms, stabilization of epilepsy is the first element to apprehend; The prescription must be optimized because some antiepileptics are at risk of pharmaco-induced psychiatric disorders (levetiracetam, tiagabine, vigabatrin, zonisamide). If one of these molecules must however be envisaged, slow and progressive titration makes it possible to limit the occurrence. In addition, when an antipsychotic treatment is necessary, aripiprazole, risperidone and sometimes haloperidol can be favored, because well tolerated in the context of epilepsy. Clozapine, however, is not recommended.
New terminology
Finally, the Pr Wissam El-Pag (Psychiatrist, Tours) expressed evolution concerning the ” Non -epileptic psychogenic crises “(CNEP), a demonstration whose name has been criticized for many years, because” marker of our representations “, And which stems from this entity which was historically called hysteria … If the term CNEP made it possible to get out of this stigmatization, it initiated another, because this qualification is based first” on what these crises are not, namely non -epileptics ». As for the term ” psychogenic », « It is an accusing term, invalidating, stigmatizing and lowering Who can slow down membership. The term functional/dissociative crises (CFD) was proposed to replace it, following the work of a panel of international experts. If the term ” crisis “Can cause confusion with those of epilepsy,” He is speaking for patients, he validates their experience ». The term ” Functional “Might seem too vague, and oppose something structural, but it is less stigmatizing than the qualifier of” psychogenic ». In any case, ” This terminology offers a certain degree of adaptation to international cultural preferences. The dissociative term is neutral and can easily be explained to the patient who can work to understand the anchoring of crises to learn to control them ».
