Sleep Disorders And Their Relation To Psychological Disturbance In Children In Epilepsy Pdf
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- Common Sleep Disorders in Children
- Epilepsy and psychiatric disorders
- Sleep disturbances among patients with epilepsy
In total, 91 articles were located in PubMed, 34 were selected for abstract reading and twelve articles were reviewed, in which the main objectives were examine the relationship between epilepsy, sleep and ADHD from several perspectives, including epidemiology, effect of comorbidities on academic performance and the factors leading to diagnostic difficulties among these three disorders RESULTS: Among the main findings, there were difficulties to start and maintain sleep in patients with epilepsy and ADHD, reduction in sleep efficiency, decreased seizure threshold, as well as behavioral and cognitive deficits in both groups. For this reason, children and adolescents with epilepsy, ADHD and sleep disorders need to be assessed carefully before initiating treatment. Our review concluded that there is an important link in this pathological triad.
Common Sleep Disorders in Children
Vadim Beletsky, Seyed M. Temporal lobe epilepsy TLE , a subset of the seizure disorder family, represents a complex neuropsychiatric illness, where the neurological presentation may be complemented by varying severity of affective, behavioral, psychotic, or personality abnormalities, which, in turn, may not only lead to misdiagnosis, but also affect the management. This paper outlines a spectrum of mental health presentations, including psychosis, mood, anxiety, panic, and dissociative states, associated with epilepsy that make the correct diagnosis a challenge.
Dostoyevsky and Parricide, Seizures are common in the general population. This suggests that in patients who are in their 30s to 40s, the onset of the recurrent generalized tonic-clonic seizures may be secondary, arising from a continuation of simple partial seizures, frequently signifying the underlying focal CNS pathology, or general medical condition, such as an altered endocrine or metabolic states. Decades ago epilepsy was considered a nosological entity within the realm of psychiatric illness, but now the diagnosis and treatment assignment is left up to neurologists by default, necessitating expertise or at least familiarity with similar clinical presentations related to other medical and mental health conditions.
Extensive collaboration or shared care with internists and psychiatrists therefore makes clinical sense, but unfortunately not always possible. The diagnosis of epilepsy is a clinical one, with the electroencephalography EEG findings supporting the diagnosis if positive, but not excluding it if negative [ 5 , 6 ].
Routine EEG, still the first choice in ambulatory setting, is augmented with continuous EEG cEEG monitoring and video-EEG telemetry, which is crucial for confirming the diagnosis of a seizure disorder where there are diagnostic uncertainties or where treatment decision is based on such confirmation [ 7 ].
The role of these diagnostic modalities varies from supportive to irreplaceable, for example, in differentiating psychogenic nonepileptic seizures PNESs when compared to other available diagnostic procedures [ 8 ]. Patients, presenting with features of a psychiatric illness, often require much more complex approach. Mirsattari et al. Indeed, clinical presentations could be easily mistaken for the variety of medical and surgical conditions, including head injury, febrile seizures, meningoencephalitis, and tumors.
Other conditions that could be commonly misdiagnosed for epilepsy include but are not limited to hypoglycemia, sleep disorders, migraines, transient ischemic attacks TIAs , paroxysmal movement disorders, and transient global amnesia TGA , just to name a few [ 11 , 12 ].
The recent advances in diffusion tensor imaging DTI appear promising in delineating the disease substrate [ 16 ]. Magnetoencephalography MEG reflecting the state of electrical activity within the neurons offers better accuracy in localizing the focus of epileptogenic activity compared to EEG due to the elimination of artifacts from the surrounding tissues and high temporal resolution.
The combination of imaging techniques with EEG, targeted at different physiological levels of brain architecture, appears most promising [ 19 ]. Despite all the above mentioned advances in imaging, clinical decision-making and EEG continue to be the cornerstone of the diagnostic approach.
In the busy emergency departments EDs , this scenario could easily lead to referral to psychiatrists, if the noncontrast head CT and lab results appear within normal limits. There have been years of debate whether or not mental health problems experienced by patients with TLE are separate comorbidities or integral parts of the same pathophysiological process.
If some disorders, particularly affective, could be attributed to global emotional response to chronic and debilitating illness i. It does therefore appear that both typical and atypical clinical presentations with, at times, layers of psychiatric symptoms evolving gradually or sporadically over the course of a seizure disorder might have the common pathophysiological mechanisms, that have not precisely been identified yet.
Seizure-like activity, at some point experienced by many, may not necessarily represent a seizure disorder per se, unless the clinical manifestation continues to unfold further in time with repeated pattern of the neurological manifestation, including abnormal sensation, motor abnormalities, level of consciousness, dysregulation of an autonomic nervous system, affective, behavioral changes, or a combination of all.
In fact, it should probably be viewed as a spectrum of seizure disorders, rather than an isolated nosological unit, with at least two subtypes, namely, mesial temporal lobe epilepsy MTLE and lateral temporal lobe epilepsy LTLE with the epileptogenic focus on the outer temporal lobe surface.
This is followed by ictal, postictal, and then interictal states. Screening for automatisms or semipurposeful seemingly automated movements , frequently observed in ictal state, should become norm in every clinical patient encounter—this is commonly missed only because a witness might not necessarily consider it relevant to report. Examples include lip-smacking, chewing or swallowing, picking at buttons, or other repetitive hand movements. Patients would often appear semireactive to their environment, picking up nearby objects such as telephones or pencils but in a trance-like state with likely no recollection of the events.
Speech output may also be automatic or semiresponsive, perseverative at times. Usually, a postictal period of either confusion or dysphasia occurs, the duration of which varies from minutes to hours, but rarely days, and sometimes inversely proportional to baseline cognitive abilities.
Other features that suggest a diagnosis of temporal lobe originating seizures include short duration minutes , early onset, and a history of childhood febrile convulsions [ 21 ]. Sleep-onset panic attacks [ 22 ] and the lack of response to typical panic disorder treatments should also raise questions. Psychiatric manifestations of epileptic seizures have been known for years, both for idiopathic cases and those describing patients with seizures with mental health abnormalities following traumatic brain injuries [ 24 ].
One recent survey on comorbidities in epilepsy [ 25 ] found that neuropsychiatric conditions such as anxiety, depression, bipolar disorder, ADHD, sleep, and movement disorders were more likely to be self-reported by patients with epilepsy than those without it.
Pathological substrate in psychosis involves the same limbic structures in TLE with or without involvement of the frontal and parietal lobes, the combination of which results in discrete psychotic phenomena [ 26 ].
The inner relationship between psychosis and epilepsy appears rather complex, but, from the practical standpoint, it may be important to distinguish these symptoms to a particular TLE phase, that is, during aura, ictal during the event , postictal after the event , interictal in-between seizures , and iatrogenic, representing anticonvulsants sideeffects [ 27 ].
Psychosis, the exact prevalence of which is difficult to estimate, can be related to each seizure event or present in a persistent fashion, fully simulating schizophrenia or schizoaffective disorder if coupled with affective dysregulation.
The clinical presentation strongly suggestive of schizophrenia may be so convincing, especially if patients present only with psychotic features [ 29 ], that in one study when formally applying criteria for schizophrenia, half of the patients with epilepsy and psychosis could have been easily diagnosed with schizophrenia alone [ 30 ].
To make matters worse from the diagnostic standpoint, there also appears to be a cohort of patients with both epilepsy and schizophrenia concurrently existing [ 31 ]. Under the circumstances, it would be prudent to pay specific attention to the onset of the first symptom or sign and the response if any to anticonvulsant or antipsychotic medication.
Even then it may not provide enough evidence to differentiate reliably. In an attempt to answer the question which of these two separate entities comes first, Adachi et al.
If true, it seems plausible that since psychosis is a purely clinical entity, the pathophysiologic mechanism responsible for generating these symptoms may be disease independent, that is, appear secondary to electric or chemical disruptions, whether idiopathic, caused by metabolic abnormalities or the host of other offenders. Not all patients with TLE, however, show these abnormalities.
There is some evidence that the age of epilepsy onset earlier age predispose patients to develop psychotic symptoms, mostly interictally [ 33 , 34 ]. Other predisposing factors include the presence of borderline intellectual functioning [ 35 ] and a family history of epilepsy or psychosis [ 36 ]. As for the psychiatric premorbid factors, high prevalence of mood disorders in first- and second-degree relatives, rather than potentially predisposing personality traits, schizotypal, and paranoid in particular, was reported [ 37 ].
Half a century ago in a classic text, Slater et al. Interestingly, there was also no uniform psychotic presentation in both patients with TLE and schizophrenics without epilepsy. Same could be attributed to the course of illness, whether relapsing-remitting or progressing. The negative symptoms, however, were thought to appear more predominantly in patients with TLE, which were deemed independent of past affective disorders and resulting in greater neuropsychological deficits [ 39 ].
Other authors [ 40 ] suggest that TLE psychosis lacks the negative symptoms of schizophrenia with more benign and variable course. From the clinical standpoint therefore, it would be safe to assume that just the presence of mostly negative or positive symptoms is neither specific nor sensitive. Since psychosis is a manifestation of the brain dysfunction symptom and not a separate disease category, duration of it offers no significant assistance in deciding the secondary process versus psychiatric illness—in both cases the duration could be highly variable as well as a severity.
Irrespective of the clinical caveats, psychosis in TLE may have either relapsing-remitting course concurrent with seizures , chronic involving interictal phase , or combinatory with various complexity and expressiveness of thought disorder or perceptual abnormalities. More complex hallucinations with experiential phenomena can follow [ 43 ], comprising dream sequences, flashbacks, and brief or prolonged profound affective symptoms such as sadness, happiness, fear, or anxiety.
Patients, usually unresponsive, may demonstrate complex behavior, including seemingly purposeful activity walking, dressing, chewing, or even repeating phrases. Patients may retain partial responsiveness [ 44 ], another strong potential for misdiagnosis. Finally, Kraft et al. The specifics of symptoms and their timing seem dependent on the spread of the seizure focus in each individual, but it is worth noting that the particular features of complex partial seizures must be absent before an ictal cause for psychosis is ruled out.
The wide variability in presentation and relative low frequency make systematic evaluation of these phenomena problematic, but identification of seizure activity leading to anticonvulsant treatment tends to result in psychiatric improvements [ 45 ] although, to the best of our knowledge, there are no randomized, controlled studies outlining this issue. Because of the frequently observed motor abnormalities, ictal psychosis may not necessarily present a diagnostic dilemma.
Because this seizure type is easily recognized by physicians and lay-people alike, there is usually no difficulty in identifying the cause. The uncertainty arises when these events do not seem related, even though rarely there is a lucid interval of one to six days prior to the onset of psychosis.
Kanner et al. As to the specifics of the presentation, it varies from grandiose and religious delusions with elevated moods [ 48 ] to mixed manic-depressive like psychosis or bizarre behavior [ 49 ]. From the practical perspective, confusion in emergency rooms in respect to the differential diagnosis stems from convulsions not being witnessed, or with appearance of the mental health problems in patients following a nonconvulsive seizure.
Thus, in an attempt to delineate the differential path, applying DSM IV criteria per se might not be sufficient—one needs to take into account the past medical and mental health history, pace of the development of psychotic symptoms, fluctuations on the level of consciousness, and, finally, the responsiveness or lack of thereof to antipsychotic medications.
Interictal psychoses seem most troublesome to differentiate from a pure psychiatric illness. Many authors would again argue that the distinction between the neurologic and psychiatric boundaries in these individuals is arbitrary or artificial [ 45 ], since the judgment is based solely on clinical observation.
Schizophrenia-like psychosis in epilepsy is not that common but well documented [ 38 ]. These individuals present quite similarly to paranoid schizophrenia with perceptional abnormalities, with a mean latency of about Clinically, factors that distinguish these patients from having pure schizophrenic illness were reported to include a typically better premorbid function, a preservation of affect, religious, moral, or ethical interests [ 50 , 51 ], absence of negative symptoms, formal thought disorder, and catatonia [ 29 , 52 ].
A study of epilepsy patients with psychosis compared to epileptic controls concluded that earlier age at onset of epilepsy mean The clinical utility of the data is debatable as the absolute differences between groups appear small. Case reports of patients with this overlap of symptoms highlight the difficulties in both diagnosis and management, even though anticonvulsants tend to improve clinical outcomes [ 54 , 55 ].
The global outcome in epileptic schizophrenic patients tends to be worse, perhaps reflecting organicity in their illness [ 31 ].
Lastly, in patients with medically intractable TLE, surgical approach may precipitate the onset of the psychotic features [ 57 ]. This process could be qualitatively different from the previously seen signs of psychosis if any , and, in other cases, psychiatric condition would just remain unchanged with postoperative seizure improvement [ 58 ].
Summarizing, symptoms and signs of psychosis may appear at any phase of the epileptic disorder and require meticulous history taking and trials of medication to speculate on exact diagnostic modality. PNESs represent the whole cluster of a seizure-like disorder, either occurring separately and independently from epilepsy or complementing it.
It could be defined as manifestation of similar if not identical signs of seizures in absence of paroxysmal neuronal discharge. Symptoms that are consciously produced for conscious reasons i. Unconsciously produced symptoms for unconscious reasons, as in conversion disorder, which include a great variety of neurological presentations, appear more appropriate description of this pathological state. Ironically, even though this phenomenon probably represents one of those cornerstone diagnostic modalities that act as s pivotal point in swinging patient care between specialties, neither neurologists nor psychiatrists have any reliable tools for diagnosis and management.
Frequently, giving the benefit of the doubt and acting out of the worst possible scenario for the sake of safety, these presentations could be diagnosed and treated as epilepsy if no apparent physiological explanation exists. Unfortunately, years could pass before the diagnosis is made—according to one study [ 59 ], the time between the onset of symptoms and diagnosis could exceed several years—the laboratory, electrophysiological, and imaging studies searching for the cause usually take extensive amount of time and resources.
In an attempt to clinically differentiate psychogenic from nonpsychogenic seizure activity, one needs to bear in mind that classic grand mal tonic-clonic presentation with tongue biting, urinary incontinence, and complete unresponsiveness during the ictal phase is rare in PNES.
Clonic muscle jerks in PNES are often symmetrical with the eyes closed, falls rarely involve serious body injuries, benign automatisms are rare, and postictal confusion, if present, does not reach the level commonly seen postictally in patients with TLE. Length of psychogenic seizures frequently exceeds 5 minutes [ 60 ]; these patients would more likely have a history of chronic pain or fibromyalgia [ 61 ], depression and dissociative states [ 62 ].
Other factors include history of childhood sexual, emotional or physical abuse [ 63 ], history of unipolar depression or anxiety disorders [ 64 ], along with somatoform and conversion disorders [ 65 ]. One could easily see psychogenic seizures as part of conversion disorder, which includes a whole array of neurological presentations involving motor, sensory, and coordination abnormalities, difficult to diagnose in emergency settings and even more difficult to treat.
Stigma of having a mental health condition, shame, and denial may make the therapeutic alliance with these patients problematic [ 60 ], and with an absence of evidence-based therapeutic approach showing significant benefit [ 66 , 67 ], patients may fall in-between family physicians, psychiatrists, and neurologist with minimal, if any, relief. In terms of management, a recent review [ 68 ] suggests different types of cognitive behavioral therapy CBT as a preferred treatment modality.
This was echoed by a pilot study by Goldstein et al. Dissociative symptoms, if not viewed in the context of epilepsy, are usually associated with the mind compartmentalizing unpleasant or severely traumatic memories from consciousness, thus associated with posttraumatic stress disorders PTSD , acute stress or conversion disorder.
In simple terms, all dissociative states to some extent embrace the disconnection of self from the surroundings as a protection mechanism. This phenomena may occur as an aura, during preictal or immediate postictal states, with or without affective component or anxiety.
Epilepsy and psychiatric disorders
To examine maternal knowledge of childhood sleep and its relation to sleep quantity, quality, and variability in a clinic sample of mothers of toddlers and preschool-age children with epilepsy. A total of epileptic children wore a wrist actigraphy to objectively assess daily sleep duration and its variability across 7 days. Multivariate linear regression models were performed to predict CSHQ sleep disturbance scores, daily sleep duration, and daily sleep duration variability in children with epilepsy. On average, mothers answered Only six 5. Maternal knowledge about childhood sleep is inadequate and decreased maternal sleep knowledge is associated with poorer and more variable sleep in children with epilepsy.
Actigraphy, behavior problems, children, epilepsy, sleep. INTRODUCTION with up to 44% of parents considering that their child has a sleep problem (Byars, Yolton, with behavioral and psychiatric problems in children without medical to our knowledge no study has explored such a relation including.
Sleep disturbances among patients with epilepsy
Mental health of children and adolescents with epilepsy: analysis of clinical and neuropsichological aspects. Epilepsy compromises the development of cognitive and social skills and represents a risk of psychiatric comorbidity. To compare psychopathological symptoms in children with epilepsy and in a healthy group, and to correlate the results with neuropsychological and clinical variables. Forty five children with idiopathic epilepsy and sixty five healthy controls underwent neuropsychological evaluation and their caregivers replied to a psychopathology questionnaire Child Behavior Checklist — CBCL. There were significant differences in CBCL, with poorer results showed mainly by patients with epilepsy.
Vadim Beletsky, Seyed M. Temporal lobe epilepsy TLE , a subset of the seizure disorder family, represents a complex neuropsychiatric illness, where the neurological presentation may be complemented by varying severity of affective, behavioral, psychotic, or personality abnormalities, which, in turn, may not only lead to misdiagnosis, but also affect the management.
It may seem strange, but there was a time when epilepsy was not clearly distinguished from psychiatric disorders. Psychiatry and neurology were not distinct professions, and the nature of epileptic symptoms was not well understood. Eventually the origins of epilepsy in the brain were clarified, while psychiatry and neurology went their separate ways. People with epilepsy and their physicians were happy to have an explanation or partial explanation that combated the social stigma still attached, in the minds of some, to psychiatric disorders.
Шестиэтажная ракета содрогалась. Стратмор нетвердыми шагами двинулся к дрожащему корпусу и упал на колени, как грешник перед лицом рассерженного божества. Все предпринятые им меры оказались бесполезными. Где-то в самом низу шахты воспламенились процессоры.
Это была цифровая мультимедийная трансляция - всего пять кадров в секунду. На экране появились двое мужчин: один бледный, коротко стриженный, другой - светловолосый, с типично американской внешностью. Они сидели перед камерой наподобие телеведущих, ожидающих момента выхода в эфир.
Странно, что она чувствует нервозность в такой знакомой ей обстановке. В темноте все в Третьем узле казалось чужим. Но было что-то. Сьюзан на мгновение заколебалась и оглянулась на заблокированную дверь.
Внезапный прилив энергии позволил ей освободиться из объятий коммандера. Шум ТРАНСТЕКСТА стал оглушающим. Огонь приближался к вершине. ТРАНСТЕКСТ стонал, его корпус готов был вот-вот рухнуть. Голос Дэвида точно вел ее, управляя ее действиями.
Но я уже забронировала номер, обиженно сказала Сьюзан. - Нашу старую комнату в Стоун-Мэнор. - Я понимаю, но… - Сегодня у нас особый день - мы собирались отметить шесть месяцев. Надеюсь, ты помнишь, что мы помолвлены. - Сьюзан - вздохнул он - Я не могу сейчас об этом говорить, внизу ждет машина.