Psych · Intellectual disability psychiatry
Epilepsy in intellectual disability
Also known as Epilepsy and learning disability · Epilepsy intellectual disability psychiatry · Seizures in ID · Refractory epilepsy ID · SUDEP intellectual disability · Postictal psychosis ID · AED psychiatric side effects ID
Exam-exhaustive fellowship reference on epilepsy in intellectual disability — prevalence and severity gradient (McGrother ~26%), treatment resistance, peri-ictal behaviour vs primary mental illness, postictal psychosis and forced normalisation, AED psychiatric adverse effects, psychotropics and seizure threshold, SUDEP and premature mortality, joint neurology–ID psychiatry care, capacity and safety. FRANZCP-primary, globally tagged.
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Red flags
- Cluster of seizures then lucid interval then new psychosis — treat as postictal psychosis until proven otherwise; high violence and self-harm risk
- Behavioural change without recovery of baseline awareness — exclude nonconvulsive status epilepticus with EEG, not psychiatry alone
- Abrupt AED withdrawal for 'behaviour' — risk of status epilepticus; never stop AEDs without a neurology-agreed plan
- New irritability, aggression or mood change after levetiracetam, perampanel, topiramate or zonisamide — review the AED before only escalating psychotropics
- Unexplained death risk education omitted — SUDEP and drowning are high-yield preventable-harm teaching points in ID epilepsy
- Valproate in a woman of childbearing potential with ID without documented contraception counselling and pregnancy prevention programme
- Do not start bupropion or high-dose clozapine in active epilepsy without a deliberate seizure-risk plan with neurology
Meet the patient
A 32-year-old man with severe intellectual disability and treatment-resistant epilepsy is sent to your clinic for "new psychosis." The notes say he had a cluster of seizures four days ago, seemed back to baseline for a day, and is now terrified, hearing voices, and refusing to leave his room. The referrer wants risperidone.[7]
The registrar reaches for the antipsychotic. The consultant reaches for the timeline. That cluster, then a lucid interval, then psychosis is the single most examinable sequence in ID epilepsy — and the right first move is to ring neurology, not the drug chart.[5][7]
References16ShowHide
- [1]McGrother CW, Bhaumik S, Thorp CF, Hauck A, Branford D, Watson JM Epilepsy in adults with intellectual disabilities: prevalence, associations and service implications Seizure, 2006.PMID 16782360
- [2]Robertson J, Hatton C, Emerson E, Baines S Prevalence of epilepsy among people with intellectual disabilities: A systematic review Seizure, 2015.PMID 26076844
- [3]Robertson J, Hatton C, Emerson E, Baines S Mortality in people with intellectual disabilities and epilepsy: A systematic review Seizure, 2015.PMID 26076855
- [4]Bowley C, Kerr M Epilepsy and intellectual disability J Intellect Disabil Res, 2000.PMID 11079350
- [5]Kerr M, Scheepers M, Arvio M, et al. Consensus guidelines into the management of epilepsy in adults with an intellectual disability J Intellect Disabil Res, 2009.PMID 19527434
- [6]Kerr MP, Mensah S, Besag F, et al. International consensus clinical practice statements for the treatment of neuropsychiatric conditions associated with epilepsy Epilepsia, 2011.PMID 21955156
- [7]Logsdail SJ, Toone BK Post-ictal psychoses. A clinical and phenomenological description Br J Psychiatry, 1988.PMID 3167343
- [8]Krishnamoorthy ES, Trimble MR, Sander JW, Kanner AM Forced normalization at the interface between epilepsy and psychiatry Epilepsy Behav, 2002.PMID 12609326
- [9]Tellez-Zenteno JF, Patten SB, Jetté N, Williams J, Wiebe S Psychiatric comorbidity in epilepsy: a population-based analysis Epilepsia, 2007.PMID 17662062
- [10]Alper K, Schwartz KA, Kolts RL, Khan A Seizure incidence in psychopharmacological clinical trials: an analysis of Food and Drug Administration (FDA) summary basis of approval reports Biol Psychiatry, 2007.PMID 17223086
- [11]Pisani F, Oteri G, Costa C, Di Raimondo G, Di Perri R Effects of psychotropic drugs on seizure threshold Drug Saf, 2002.PMID 11888352
- [12]Mula M Epilepsy and Psychiatric Comorbidities: Drug Selection Curr Treat Options Neurol, 2017.PMID 29046989
- [13]Devinsky O, Hesdorffer DC, Thurman DJ, Lhatoo S, Richerson G Sudden unexpected death in epilepsy: epidemiology, mechanisms, and prevention Lancet Neurol, 2016.PMID 27571159
- [14]Fisher RS, Cross JH, French JA, et al. Operational classification of seizure types by the International League Against Epilepsy: Position Paper of the ILAE Commission for Classification and Terminology Epilepsia, 2017.PMID 28276060
- [15]Deb S, Kwok H, Bertelli M, et al.; Guideline Development Group of the WPA Section on Psychiatry of Intellectual Disability International guide to prescribing psychotropic medication for the management of problem behaviours in adults with intellectual disabilities World Psychiatry, 2009.PMID 19812757
- [16]Trollor JN, Salomon C, Franklin C Prescribing psychotropic drugs to adults with an intellectual disability Aust Prescr, 2016.PMID 27756975