The article identifies and presents ten issues that make the psychiatric emergency of epileptic nature a very complex and difficult clinical reality. However, the practice allows the delineation of five different framework conditions in terms of grouping the diagnosticobstacles that have to be overcome

Introduction

It is a subject apparently limited to one aspect of the problems raised by a single neurological disorder. In reality, it is an extremely complex and difficult domain for many reasons.

Ten aspects that transform the psychiatric emergencies in epilepsy into a difficult problem:

Firstly, because they have a multidisciplinary character with four facets: • a neurological one; • a psychopathological one; • a somatic one; • and a therapeutic one. Moreover, sometimes they have forensic implications. The latter refer to the obligation of recording the information on discernment, danger and consent of the content of assistance. As such, the doctor called to provide first aid is required, under limited time and with modest means, to consider and cover by him/herself the necessary knowledge related to all these areas.

Secondly, because on the one hand, in terms of aetiology, epilepsy is a heterogeneous disease, summing up several clinical realities that are constantly diversifying. One has to highlight the existence of symptomatic epilepsy that raises very special problems in case of emergency, too.

On the other hand, psychiatric emergencies that are epileptic in nature are different. They may be the expression either of paroxysmal epileptic manifestations having intra or postictal character, or of the background organic and functional disorder complex which caused, characterize or accompany epilepsy. Here lies also the entire abnormal substrate underlying the intercritical disorders.

Thirdly, the epileptic focus can be located or can involve any structure of the brain. In full agreement with Ervin (1976), we can say that there are few psychopathological phenomena that cannot be encountered as epileptic manifestations, too. They start with the five degrees of disturbance of consciousness described by Landolt (1956) in the case of epileptic absence and end with schizophrenic – like chronic psychosis or with personality disorders (Table 1), each with forms that may be described as emergencies. To this, one may add the possibility of complications and of certain comorbid or associated conditions. Their prompt delimitation is crucial, as both diagnostic problems and those concerning the urgency of therapeutic intervention are, in each case, in many respects, different. As for the absence seizures, a particular aspect should be emphasized, namely the urgency of diagnosis and of the specific treatment for the prevention of various consequences, sometimes very serious, in case the absence occurs in certain situations involving risk of accidents.

Fourthly, risks that require emergency intervention are also very varied including both the risks of a neurological affection and those of the psychopathological domain. Aggressive states, hallucinations, impulsivity, narrowing the field of consciousness, anxiety, depressed moods, choleric attacks, affective seizures and panic seizures, delusional beliefs, inability to appreciate correctly the reality and the consequences of the acts that can be committed and ignoring the dangers, all these require emergency response because they involve: life threatening risk for oneself or for the others as well as the risk for material goods, and psychological risk represented by the need to alleviate the emotional states that generate intense suffering.

Life threatening risk is represented not only by the negative ending due to various mechanisms (asphyxia, cerebral haemorrhage, cardiorespiratory failure or head trauma) possible in a grand-mal seizure, but also by the possibility that the patient may commit suicide or assault those around him, including his family members. In fact, it is known that excessive conflicts, irritability and outstanding aggression often accompany psychiatric disorders such as epilepsy. Moreover, the response to disease, as well as the stigmatizing attitude of the entourage may also account for the self or hetero-aggressive behaviour.

Fifthly, psychiatric emergencies within epilepsy range benefit mainly from therapeutic specificity, respectively from response to antiepileptic medication. It is a prerequisite for therapeutic success and an advantage. Moreover, the existence of a specific treatment offers the possibility to prevent the occurrence of emergencies by administering regular and correct antiepileptic treatment. However, the therapeutic specificity forces the physician to establish the treatment immediately, and often, based only on the clinical criteria of the moment, on the epileptic nature of disorders. This time, adopting an attitude of expectation, specific in psychiatric emergencies of a different nature, which consists in administering symptomatic, respectively sedative medication in case of productive agitation states, or in stimulation in case of manifestations of psychomotor inhibition, is not only inefficient but also risky. In addition, this not only because some easily accessible neuroleptics (like chlordelazine or haloperidol, for example), have sometimes a seizure effect.

Administration of antiepileptic medication as a test has its own risks – inefficiency, and the possibility of a voluntary ingestion of drugs, including antiepileptic drugs. In other words, the most important emergency among other psychiatric emergencies that are epileptic in nature, is the correct diagnosis of the epileptic nature of mental disorders.

Sixthly, epilepsy can mimic psychiatric disorders (Table 2) and not just the ones that are classically called psychic equivalence. In turn, some mental disorders can mimic epilepsy and here we shall illustrate only with the phenomenology of conversion. As noted above, the optimal solution for psychiatric emergencies that are epileptic in nature imposes the obligation to establish a diagnosis of certainty on the spot and not just the identification of the epileptic nature of the disorders. The same urgency is required to indicate whether these manifestations are expression of a crisis, or forms of status epilepticus, or a postictal state or inter-ictal phenomenology. However, certainty is not easy to obtain and not only for the reasons already mentioned. Especially, in case of intercritical epileptic mental disorders, the necessary information is either vague or missing. This is even more so, this time, because neither the beginning, nor the abrupt ending of anterior manifestations and neither the acute onset of the present one, nor the intracritical EEG examination (which are solid diagnostic guidelines for critical epileptic manifestations) are always firm diagnostic elements. Moreover, the perception of epilepsy as a stigmatizing condition makes the patient to hide his suffering, an attitude favoured by current medications, which often controls crises well enough. As a result, those around the patient do not always know the data on the presence of the disease, so important for diagnosis.

Seventhly, in case of psychiatric emergencies that are epileptic in nature, it should not be ignored the fact that we are in front of a patient, who is usually under the influence of antiepileptic medication, that may be sub-dosed, overdosed, or taken to commit suicide and that it can interact negatively with medications routinely administered in other psychiatric emergencies. Therefore, each of these situations necessarily requires to be identified and to adjust the therapeutic conduct appropriately. Moreover, anti-epileptics may in turn induce urgency following polytherapy or intolerance phenomena – confusional state (phenytoin and carbamazepine) delusional and hallucinatory (carbamazepine), agitation (valproate), agitation and aggression (clonazepam ).

Eighthly, electroencephalographic examination, very useful in diagnosis when it provides meaningful data, in case of emergency, it is either not available or cannot be performed because the patient’s opposition or it is not necessarily conclusive. The last situation is characteristic to mental disorders of epileptic nature in intercritical or postcritical period. It is known that (see Milea and Roman -1988) such periods are characterized by the presence of aggressiveness, aggressive acts, impulsivity, anxiety, agitation, and delusions of persecution.

Moreover, in case of epileptic psychoses, one sometimes could meet what was called “hyper-mature” EEG trajectory.

1. The idea of their epileptic nature was and continues to be disputed. Existing data converge to support the character of their multifactorial nature, emphasizing the involvement of many factors, in proportions varying from one case to another. Such factors are: organic brain lesions that accompany epilepsy; the scale and location of these lesions; the type, complexity and frequency of seizures; the patient’s sex and age at onset; response of the patient and of those around him to grief; genetic factors and even the therapy itself.

Ninthly, although a number of clinical issues suggesting the epileptic nature of the emergency are described, in psychological manifestations with epileptic substrate, the presence of those particular clinical issues is neither mandatory, nor specific. One should consider the following aspects:

• existence of certain clinical history and of indisputable epileptic EEG;
• recurrent and relatively stereotyped character;
• spontaneous, unprovoked and unexpected occurrence;
• penchant for brutal installation, alert development, and quantitative or qualitative disturbances of consciousness;
• simple and unorganized behaviour;
• obvious discrepancy between motivation or excuse, on the one hand, and the intensity of response and severity of the consequences, on the other hand;
• absence or fragility of measures meant to cover the traces of the undesirable deed and of the perpetrator;
• as well as the presence in the patient’s pockets of antiepileptic drugs or of some revealing documents.

Tenthly, it should not overlooked the fact that, especially in mental disorders in of epileptic nature, for various reasons, sometimes not only the patient is unable to cooperated because he is unconscious, but also he can hide data, or he may oppose intervention or act aggressively.

Of course, all these difficulties can be overcome having in mind, in any emergency with mental phenomenology, the possibility that there is an epileptic substrate, and using anamnesis and clinical examination (and, if it is accessible, the laboratory) all these rigorously focused on identifying suggestive data on the epileptic nature of the disorders. As already pointed out, these are but indicative elements whose presence does not exclude the risk of being deceived. Moreover, they may be missing, incomplete or may be distorted by the entourage while the abrupt onset, alert development and the disorders of consciousness are real obstacles in the way to obtain sufficient information. In these circumstances, the practice can individualize at least five cases defined by the different context of the problems usually posed by the firm answer to the question whether we are in front of a psychiatric emergency of epileptic nature.

Five possible types of psychiatric emergency having epileptic nature

1 Emergency considering that, in addition to the information currently provided by clinical appearance, we do not possess any other data. It is the most difficult situation. It is not an exception because it is favoured by the fact that the disturbances may occur suddenly, unexpectedly, without previous warning, are accompanied by impaired consciousness and usually, out of well-known reasons, the patient keeps his suffering secret. In addition, naturally, the doctor is not present from the moment of occurrence of the events. Therefore, he is confronted with postictal states while data about what had happened are offered by whoever is available or by too many people, their quality being affected by the dramatic event. Moreover, the control of the pockets in order to identify the presence of drugs or of relevant medical documents is often negative, too. Such cases require a quick and thorough clinical somatic, neurological and mental examination, a routine fundus examination, solid professional knowledge, orderly mind and experience in the field in order to be able to assess the diagnostic hypotheses offered by the different information available. There are reasons that would require the provision of an ophthalmoscope, the ability to use it and, for each epileptic individual, there should be a requirement to carry a document certifying that he is epileptic.

2 Emergency in a patient with known history of epilepsy. This aspect is favoured by the fact that epilepsy is a disease of long duration, with recurring events that require continuous treatment and, not infrequently, social support.

That does not mean that we are certainly confronted with epileptic events. The following will have to be considered and excluded:

• Psychiatric disorders in the frame of symptomatic epilepsies (infectious, tumoral, traumatic, vascular, etc.) that have to be identified and dealt with according to the nature of the underlying disease.
• Psychiatric disorders within comorbid and associated diseases such as diabetes and hypo-or hyperglycemic events, which are to be targeted specifically.
• If manifestations are clearly present within or following a grand-mal seizure, the possibility of a brain injury caused by the seizure should not be overlooked. Also, one should not omit the possibility that an accidental head trauma might be at the origin of the manifestations suggesting a grand mal crisis.
• Of course, the possibilities of a drug overdose, of drug intolerance phenomena and, why not, a suicide attempt should be considered, too.
• And, finally yet importantly, the presence of disorders associated by chance.

3. Patient with the presence of clinical signs suggestive of epilepsy. Neither this time should one be sure that is faced with epileptic events nor can they be minimized starting from the fact that they usually resolve spontaneously.

This time, besides the problems evidenced above, there is the concern to remove carefully all psychiatric disorders that they may mimic and to identify epileptic symptom manifestations in other diseases.

4. Patient with negative history concerning epilepsy. One should not minimize the possibility that there might be a debut.

5. Patient with inconclusive EEG. Today this situation is more and more possible because access to EEG examination is increasingly easy. The mistake to exclude epilepsy affiliation of psychiatric disorders with ease should clearly not be made. We are forced to think and to exclude:

• Postictal states,
• Intercritical psychic disorders.

Bibliography

1. Ervin F., (1976) Organic Brain Syndromes Associated with Epilepsy. In Comprehensive Textbook of Psychitry (sub red. Freedman a și colab.) ed. II-a. The Williams and Wilkins Co. Baltimore.
2. Landolt H. (1956) Die Bedeutung der electroencephalographie für die Behandlung Epilepsie. Tag Dtsch. Gesundh., Berlin.
3. Milea St., Roman I., (1988) Tulburări psihice în epilepsie. În: Psihiatrie vol II. Sub red.Predescu V. Ed. Medicală București

Correspondence to:
Acad. Prof. PhD, Consultant, Pediatric Psychiatry Clinic Bucharest