Men ought to know that from the brain, and from the brain only, arise our pleasures, joy, laughter and jests, as well as our sorrows, pains, griefs, and tears. Hippocrates (c 400 B.C.)

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Men ought to know that from the brain, and from
the brain only, arise our pleasures, joy,
laughter and jests, as well as our sorrows,
pains, griefs, and tears. Hippocrates (c 400
B.C.)
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Epilepsy, brain and mind Dr Niall Pender Clinical
Neuropsychologist Beaumont Hospital National
Neuroscience Centre Dublin, Ireland
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Important facts about brains and epilepsy

• Brains are complex organs that work mainly on
  electricity
• Different parts of the brain manage and control
  different activitiesbut they are all
  inter-connected
• Brain and mind are indistinguishable!
• There is a relationship between epilepsy, brain
  function, psychological state (mind) and the
  world around us.

The brain is a little saline pool that acts as a
conductor, and it runs on electricity. Judith
Hooper and Dick Teresi (from The Three-Pound
Universe, 1986)
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Vicious Cycle in Epilepsy
Adapted from Lorig et al, 2006
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How are epilepsy, brain and mind related?

• There is a relationship between brain (damage)
  and behaviour (thought and emotion)
• AND
• These difficulties can affect individuals (and
  their families)
• AND
• We can identify and manage these difficulties.

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IntroductionsEpilepsy and the brain!
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Introduction

• Epilepsy is defined by a group of conditions
  characterised by recurrent provoked seizures
• A seizure occurs when the brain's nerve cells
  misfire and generate a sudden, uncontrolled surge
  of electrical activity in the brain.
• The epilepsies are common
• 1-2 prevalence
• 50 million worldwide
• Cause is often unknown
• 60 seizure free without side effects
• Often only treating symptoms with medication
• Associated cognitive and emotional side effects

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Classification

• Generalised
• Primary (genetic)
• Absence
• JME
• GMUA
• Symptomatic
• West syndrome
• LGS
• PME

• Partial
• Genetic
• Benign rolandic
• Benign occipital
• Acquired (Lesional/ Non-lesional)
• Temporal
• Frontal
• Occipital
• Parietal

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Epilepsy, brain and mind

• Location of functions in the brain
• Lateralisation of functions to sides of brain
• Damage to brain structures can alter brain
  function
• Behavioural state
• Cognitive functioning
• Emotional state
• Specific Tests can identify these skills and
  abilities.

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What is the brain?
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FACTS

• The adult human brain weighs 3lbs
• It represents 2 of total body weight
• But uses 20 of total energy
• There are 100billion neurons
• Neuron, dendrites and an axon.
• There are three layers of covering
  called..meninges
• Dura mater, arachnoid mater and pia mater
• LOC occurs 8-10 seconds after loss of blood to
  the brain brain damage after 4 minutes

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Lobes of the brain

• The frontal lobes make up 41 of total cerebral
  cortex volume

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MRI Lesional Epilepsy
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Psychological Consequences of Epilepsy Epilepsy
and the mind!
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Different forms of epilepsy have different
symptoms

• Temporal lobe epilepsy is most often associated
  with cognitive and behavioural changes due to the
  importance of these structuresgenetic factors
• However, other forms of epilepsy such as primary
  generalised epilepsy have been shown to have more
  subtle but equally disabling difficultiesattentio
  n

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1. Cognitive (thinking) Difficulties
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Cognitive

• These skills can be affected in epilepsy and can
  have a significant impact on education,
  occupation and day to day life.
• The most commonly reported changes are in
  attention and concentration as well as memory.
• Others can report word finding difficulties and
  especially fatigue.
• Poor thinking speed can also reported

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Why?

• Our brains have a number of systems that enable
  us to take in and use information which can
  easily be disrupted but.forgetting things is
  normal
• Sometimes in epilepsy these skills can be
  disrupted making it harder for people to learn
  and use information.
• Seizures often arise in the memory centres and
  these can disrupt learning and remembering.
• Some anti-convulsants can also cause poor memory

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Neuropsychological examination

• General abilities
• IQ measures and verbal .v. non-verbal differences
  help us examine the consequences of brain changes
• Memory
• Verbal v non-verbal recall and recognition
  memory Learning
• Executive processing
• Behavioural control, problem solving, reasoning
• Language functioning
• Perceptual ability
• Thinking speed

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Attention and memory

• Memory lapses are common
• Attention a key gateway to memory but is easily
  impaired
• It is a system to allow us to prioritise activity
  and monitor performance.
• Poor attention leads to poor memory
• Seizures, medication, alcohol, reduced sleep,
  stress/anxiety all affect attention
• Day to day difficulties experienced but on
  testing no deficits apparent.attentional loss

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Epilepsy and intellectual function

• Epilepsy is common in individuals with an
  Intellectual Disability
• The frequency of epilepsy in people with a
  learning disability is higher than in the general
  population. About 30 of people with a learning
  disability also have epilepsy. In people with a
  severe learning disability at least 50 also have
  epilepsy.
• The more severe someone's learning disability is,
  the more likely it is that they will also have
  epilepsy.

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Epilepsy and psychological functions

• Can anti-epileptic medication cause side effects
  or changes in behaviour?
• Some people may react badly to their
  anti-epileptic medication. A brain that has been
  damaged is more prone to possible side effects.
  Sometimes side effects include poor attention,
  restlessness and slowed or unsteady movement.
  These may be difficult to tell apart from the
  signs of the underlying damage to the brain. If
  someone is not able to communicate what they are
  feeling, this may result in withdrawn or
  challenging behaviour.
• Can epilepsy impair cognitive functioning?
• Cognitive difficulties in people with learning
  disabilities are usually due to the underlying
  brain damage that caused the epilepsy rather than
  the epilepsy itself. If the seizures are well
  controlled and the drug regime is kept simple,
  further cognitive difficulties are less likely.
  If seizures are poorly controlled or very
  frequent they may affect the person's overall
  quality of life. If seizure control increases
  these difficulties may also improve.

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2. Emotional features
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Epilepsy and depression

• Major depressive disorder in 8-48 with an
  average of 29(Herman et al, 2000)
• Weigartz et al. (1999) 30 major depressive
  disorder, 25 dysthymic disorder

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Epilepsy and depression (2)

• Reaction to epilepsy label
• Reaction to social/family/lifestyle difficulties
• Seizure related phenomena
• Some depression unrelated directly to seizures,
  but possibly to increased frequency
• Depressive symptoms related to other mental
  illnesses.

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Epilepsy and anxiety

• 25-33 of people with drug resistant epilepsy
  suffer anxiety
• Higher incidence of social phobia in epilepsy
  sufferers

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Non-Epileptic Seizures or Non-Epileptic Attack
Disorder (NEAD)

• Betts (1991) a sudden disruptive change in a
  persons behaviour which is usually time-limited,
  and which resembles, or is mistaken for,
  epilepsy, but which does not have the
  characteristic electrophysiological changes in
  the brain detectable by EEG, which accompanies a
  true epileptic seizure.
• Imparting the diagnosis of NEAD is the first step
  to successful treatment
• New diagnosis must lead into psychological
  treatment ideally within the same service
• Flexible approach to treatment as responses to
  diagnosis will vary

Thanks to Dr Gillian Fortune
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NEAD Categories Co-morbidity

• ORGANIC NEAD Cardiovascular Cerebrovascular
  Migraine (espec. Basilar) Alcohol-related
  Post-anaesthetic Pre-eclampsia
• PSYCHOGENIC NEAD Conversion Disorder
• Psychological/Emotional/Personality causes
• Psychological Conditions Associated with NEAs
• Depression 25-60
• Anxiety disorders 12-50
• Personality disorder 30-60
• Other Conversion disorder 30-80
• e.g. numbness, weakness, blindness, fainting,
  paralysis
• Alper et al (95)
• 25 of NEAs accounted for by Panic disorder,
  psychosis, ADHD, depersonalisation disorder

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Self-management
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Vicious Cycle in Epilepsy
Adapted from Lorig et al, 2006
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Obstacles to self-management
Knowledge
Family support
Seizures types Medications
Attitudes
Care Lifestyle
Skills behaviours
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What can we do?

• Awareness and identification of problems are
  first
• Considering epilepsy as a serious health problem
  that must be addressed
• Improving self-management of epilepsy
• Medication
• Seizure factors
• Lifestyle
• Improved coping

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Better self management comes from

• Freedom in decision making
• Authority
• Support
• Responsibility
• Education is vital to this process
• Need more educational programmes for people at
  different stages in the illness of epilepsy
• Living Well With Epilepsy II (2003)

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Fatigue

• Fatigue is one of the most commonly reported
  symptoms in neurological conditions
• It is also the most concerning aspect to
  patients
• Patients describe
• Tiredness
• Weakness
• Inability to generate muscle force
• Inability to sustain mental or physical
  performance.
• Related to CNS dysfunction, poor immune
  regulation, chronic illness effects

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Important factors to consider when working
cognitive difficulties

• Do not overload person with lots of demands
• Little and often is important
• Information processing can be slow.dont rush
• Reduce distraction where possible
• Patients fatigue very easily.give rests
• Use diaries, memory aids, calendars and others
  such as phone to support your memory

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Other changes The old favourites-lifestyle!

• Nutrition
• Exercise for fitness general well-being
• Medication, discuss worries with team
• Relaxation to manage anxiety
• Education on the illness and skills
• Memory, emotion etc
• Communicating fears and worries

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Overall

• Learning to self-manage is not about isolation
  and going it alone!
• It is about taking over the management of your
  illness and learning to break the vicious cycle
  to give you more control over an often
  unpredictable illness
• This method has been effective in other chronic
  illness and is part of a general focus on many
  lifestyle factors in health

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Thank you!