Psychiatric comorbidity in patients with developmental disorders and epilepsy: a practical approach to its diagnosis and treatment

https://doi.org/10.1016/S1525-5050(02)00536-XGet rights and content

Abstract

Psychiatric comorbidity in patients with developmental disorders and epilepsy (PDDEs) is relatively frequent. The majority of its pharmacological treatment has consisted of the use of neuroleptic drugs in an attempt to control behavioral disturbances, despite the fact that these symptoms may often mask underlying psychiatric disorders such as anxiety and depression, which require other types of psychotropic drugs. In this article, we review the pathogenic mechanisms that mediate the clinical manifestations of psychiatric disorders in PDDEs, highlight diagnostic strategies that may help in elucidating the correct psychiatric diagnosis, and review the psychopharmacological treatments available.

Introduction

The prevalence of epilepsy in developmentally disabled patients (DDPs) ranges from 30% among patients with mild mental retardation to 50% in severely retarded individuals [1]. By the same token, the prevalence rates of psychiatric comorbidity in DDPs have been estimated to range between 10 and 60% [2]. Whether epilepsy increases the risk of psychopathology in DDPs is still debated by several authors. Lund [3], for example, found that the prevalence rate of psychiatric disorders in patients with developmental disabilities and epilepsy (PDDEs) was significantly higher among those with persistent seizures than among seizure-free patients. Deb and Hunter [4] failed to confirm these findings, however. PDDEs may experience all forms of psychiatric disorders, but aggressive (self- and outward-directed) and impulsive behaviors are the most frequent overt expressions of psychopathology. In this article, we review various strategies that can be helpful in the diagnosis and pharmacological treatment of different types of psychopathology in PDDEs.

Section snippets

Psychopathogenic mechanisms in DDPs

DDPs are not protected from the various psychiatric disorders afflicting cognitively intact populations. Careful evaluation has revealed the occurrence of depression, attention-deficit/hyperactivity disorder (ADHD), anxiety, and psychotic disorders. Yet these disorders often go unrecognized because of the patients’ inability to verbally communicate their symptoms. The clinical expression of these disorders often consists of symptoms of agitation, self-injurious behavior (SIB), and aggression,

Psychopathogenic mechanisms in PDDEs

The pathogenic mechanisms operant in various psychiatric disorders of cognitively intact patients with epilepsy are expected to have the same impact in PDDEs. In some PDDEs, these mechanisms may result in cognitive and psychiatric disturbances that may be reversible after control of the epileptic seizure activity, while in others they become irreversible despite the achievement of freedom from seizures. An example of reversible psychiatric comorbidity is the development of aggressive behavior

Psychiatric disorders in PDDE

Evaluation of psychiatric comorbidity in epilepsy requires the identification of any temporal relationship between the occurrence of seizures and psychiatric symptomatology, which may be classified into one of four categories: preictal, ictal, postictal, and interictal. Among PDDEs, preictal psychiatric phenomena present as unprovoked irritability and poor frustration tolerance that often resolve after the ictal event [30]. Ictal psychiatric phenomena are extremely rare and present as prolonged

Treatment of psychiatric comorbidity in PDDEs

Despite the relatively high prevalence of psychiatric comorbidity among epileptic patients, its treatment remains an unexplored territory. Accordingly, the available data are based on anecdotal reports or open trials. Clinicians in general have displayed a certain degree of temerity in using psychotropic drugs in patients with epilepsy, for fear (much of which is unfounded) of exacerbating seizures. Principles to consider when using psychotropic drugs in PDDEs are reviewed below.

Conclusion

Psychiatric comorbidity is relatively frequent among PDDEs. While aggressive behavior and SIB often mask underlying endogenous psychiatric disorders, a careful evaluation of the patient’s personal clinical signs and family history can yield an accurate diagnosis. Iatrogenic mechanisms are frequently the culprits of psychiatric disturbances and should be suspected in all patients in whom psychiatric symptoms develop following modification to AED regimens or when associated with significant

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