Epilepsy in Uganda

[00:00:01]2017 2025.

[00:00:04]Focal onset seizure um is now being called a focal seizure. Generalized onset seizure is a generalized seizure.

[00:00:12]Awareness as a classifier is now being called consciousness which is defined as awareness plus responsiveness. Then motor versus non motor is observable versus without observable manifestation.

[00:00:27]And then I've already talked about the number that has moved from 63 to 21. And then first symptom used to be emphasized a lot but now in the 2025 classification is chronology um being emphasized.

[00:00:43]So this matters to psychiatrists among other um other cers that clearer terminology improves communication with um with other colleagues neurologist and the like. Um emphasis on observable manifestations aligns with psychiatric history taking and then recognition that conscious impairment can be partial important when distinguishing epileptic from psychiatric events. Okay. So I've highlighted this. So focal aware changes in focal aware seizure became focal preserved conscious consciousness seizure and then focal impaired awareness becomes focal impaired consciousness seizure. Unknown onset seizure became unknown whether focal or generalized.

[00:01:46]it brings some more clarity.

[00:01:49]And the other thing that has been emphasized now is the definition of consciousness. Um, and how to deal with this in our day-to-day clinic settings during a seizure. How to assess consciousness during a seizure is now defined by two components.

[00:02:05]Um, one awareness which is recall.

[00:02:13]So you ask the patient could you remember what happened during the event and this brings up very interesting answers. So yes, no.

[00:02:28]Responsiveness, could you respond to others during the event?

[00:02:33]Okay, is another question you can ask.

[00:02:38]So how do you go from here? If both awareness and responsiveness are intact that is preserved consciousness.

[00:02:48]If either awareness or responsiveness is impaired you will call it impaired consciousness.

[00:02:57]I hope that is very clear.

[00:03:01]If the patient had ecopasia, okay, but could respond to nonverbal cues, consider that as preserved consciousness. Some forms of epilepsy, um the patient, um just it gets mute and it's related to the seizure, but they can't talk. Um so we we but they can respond to you rather. Okay. So if patient has ecto amnesia but was responsive consider as preserved consciousness.

[00:03:46]So um the clinical implications and special considerations here children who are less than four or five years awareness may be difficult to to may not be as accessible.

[00:04:03]So you might rely only on responsiveness and then um ectophasia.

[00:04:11]So unresponsiveness may not indicate impaired consciousness. That's very important to to know.

[00:04:20]Ectoparasis motor impairment may not indicate impaired consciousness.

[00:04:33]Post ectonesia not ecto does not alter classification.

[00:04:40]I hope that makes sense.

[00:04:43]So if The thing to save in our memory is that if the state of consciousness is unknown, classify under the parent term focus seizure or seizure of unknown origin.

[00:05:04]When taking history, ask specifically, could you remember what happened? And then I've I've already highlighted that.

[00:05:11]Um so there's still other important things that I'd want to share more on um with the classification, but the gist of this of the study goes beyond this.

[00:05:33]So I'd like to skip this part of the presentation that breaks down the different types of um seizure seizure classifications.

[00:05:49]on to um something else. Key syndromes perhaps every um psychiatrist should know um childhood absence epilepsy.

[00:06:01]um typical three heart spike pictures on the EEG and this is the classical age and the child has very many um seizures per day and usually comorbid with ADHD learning difficulties depression and anxiety JME juvenile myoconic epilepsy usually that's the age range 10 to 24 and with myoconic Jackson awake wakening and um photosensitivity um depression, anxiety, impulsivity, social isolation or common psychiatric um coorbidities. DVET happens within the first year prolonged February seizures and genetically there's the SCN1 1A mutation typic shows up with ADHD mut autism and um other behavioral disturbances. Lenox usually shows up in children less than eight years. Multiple seizure type presentations and slop spike wave on the EEG. Intellectual disability and behavior problems are common. Um psychiatric presentation, idiopathic generalized adolescent epile adolescent adults.

[00:07:18]Um GTC myonic usual executive functioning gets impaired impulsivity attention problems are also seen.

[00:07:28]So um when differentiating these seizure types um age of onset usually childhood for generalized epilepsies um focal epilepsies usually at any age or are not common in generalized epilepsies while they're common and location specific. So eg sensory or epigastric ectoe events.

[00:07:55]Um so absence myonic tonic chronic are the ecto events in generalized epilepsies while focal epilepsies usually have focal awareness or impaired awareness of focal bilateral um tonic clonic um ecto events.

[00:08:21]The postto events commonly after generalized seizures not after absence and myoconic that's for the generalized epilepsies and then common after all except focalized epilepsies have positive family history of um epilepsy and they're rarely positive in um in the FOC except in familiar cases risk factors may be absent in generalized while there is may be a risk factor like trauma infection or stroke in the epilepsies.

[00:09:01]The EEG features a generalized spike wave while focal epileptic form discharges um in the the EEG or the focal epilepsies.

[00:09:15]Most MRIs are normal in generalized epilepsies and are not necessary for diagnosis.

[00:09:22]Um if an MRI is done for focal epilepsies, you'll see some structural abnormalities.

[00:09:28]Um so where does that take us?

[00:09:37]The interface between um psychiatry and epilepsy.

[00:09:42]Um we've talked about these u coorbidities we hadn't touched on the psychosis interto between the seizures. 7% um have a 6 to 12 times more frequent more likelihood of getting psychosis than the general population.

[00:10:08]I hope this this makes sense why um psychiatry can't run away from epilepsy and vice versa. The psychosis rates are this high compared to the general population. The depression rates are this high. Cognitive impairment is variable but up to 50% for those who get chronic epilepsy. Personality disorders are increased especially intercctoral dysphoria, ADHD elevated in pediatric epilepsies and suicidality is um more than 5% in some cases five five times higher.

[00:10:47]So some of the psychiatric symptoms related to the seizures itself not functional. So precto hours or days we used to call this the prodrome this pto thing hours or days before the seizure the patient may feel a certain combination of um symptoms which may range from um irritability, dysphoria, anxiety, insomnia. Some feel sick, some even get nauseated.

[00:11:18]Um some may get um headaches and this happens before way before it can even be a whole week before um the seizure event happens. And then the seizure itself um sometimes they feel fear and when there's fear ectoear um you know that the amygdala is involved. So thoughts of a temporal lobe involvement is higher. Um again laughter galastic seizures can be one of the presentation.

[00:11:54]Then we think of a hypothalamic hematoma or again all these things are within the temporal lobe area.

[00:12:02]Crying disgrastic um seizures typically associated with the temporal lobe or frontal lobe. then ectopanic um may mimic a panic disorder perfectly.

[00:12:18]The after seizures um or postto confusion, agitation, depression, psychosis, suicidal ideiation are typical. Um then the postto psychosis is a psychiatric emergence just to pull it out of the rest. uh metas in 2% of epilepsy patient in raises after lucid interval 4 to 48 hours.

[00:12:43]Hallucinations, delusions, religious persecuto aggression is very very common very common in um postto psychosis in um in epileps in in most patients who get um these epileptia attacks.

[00:13:01]do not um the critical thing is that um it does not respond to antisychotics alone. Treating underlying seizure activity is essential. What this really says um if you have misdiagnosed and you just see the psychosis and you do not manage the um the seizure the seizures appropriately or optimize the AEDs, you get in trouble.

[00:13:29]So let me um try to fly these things are going to be shared with you. Um key is 20 to 30% um psycho non psychoggenic um non-epileptic um spells or we could call it um let me let me put it down to the features will be a conversion disorder presenting has seizures. That's that's what penis is. And in your clinic, look out for the following. Precto headache, eye closure during the seizure, waxing and waning motor activity. The the waxing and wing motor activity is basically um there seems to be a rhythm to this this um thingy and it's slow breathing sometimes side to side.

[00:14:36]We have about five minutes left. So >> Oh, good. Okay.

[00:14:41]>> So this is um CBT is the main stay for that. Let me get to the to the juice of this presentation in this five minutes.

[00:14:50]These things we're going to see we're going to to deal with. Why is it a big deal the case for Ali detection? Why should we bother to diagnose Ali?

[00:15:03]Um, these are some of the studies that I tried to to take to to break down. How long does it take for epilepsy to get diagnosed?

[00:15:15]Um, in Finland they diagnose at 12 months.

[00:15:23]Um specifically they even broke down broke this down to focuses there's a delay for them they're counting it in months in Uganda um Dr. Mukasa and Dr. and professor did a study and found that the average average delay to diagnosis ranged between 2 to 5 years in Uganda. So ours is way worse by the time you get to see the person they've been convulsing for so long.

[00:16:02]And so most more than 77% of the patients had had two seizures before diagnosis.

[00:16:12]45 had had three to 10 seizures before treatment.

[00:16:16]Okay. 15% had diagnostic delays greater than 10 years.

[00:16:22]So this is how serious this is. Okay. Um so the key thing that these studies show is that at a time many patients I evaluated they've been having recurrent undiagnosed seizures and these have significant consequences.

[00:16:43]Why the delay is important or why most diagnosises are delayed is because if the seizure is not generalized tonic chronic It will be missed on average.

[00:16:59]If there are some behavioral manifestations, semi-automatic activities, most time people will not think of it as as epilepsy. So it will be missed.

[00:17:09]Okay. So jau deja vu depersonalization, fear presentations, all those will ultimately get get missed. So the consequences of delayed recognition result in delayed treatment and seizure progression, injuries, motor vehicle accidents, progression to um sudep. Sudep is sudden death in epilepsy. We see that fairly often in in Bhutavika. It's it's one of those interesting um things. There's a hidden cost to these preventable injuries. USA has studied and found that 5% of people who um get into motor vehicle accidents have epilepsy.

[00:17:58]They've either been driving or get get knocked in some form.

[00:18:04]And then um this is um 1,816 motor vehicle accident due to undiagnosed non-mo seizures. There's a there's an economic cost to this. Um, but the key thing I want us to think of in this is something physiological that the effect of convulsing on the nerve centers is such um on the nerve centers is such as to render the occurrence of another more easy to intensify the predisposition that already exists. Thus every feat may be said to be in part the result of those that have preceded it and the cause of those that will follow it. And so the observation is people will have one seizure today and have another one at the end of the year and those will be two seizures in a year but in the subsequent year they'll have four seizures. In the subsequent year they may have up to 50 seizures.

[00:19:12]Okay? One seizure generates another seizure.

[00:19:16]Okay. Um cognitive development um you're going to find this um studies attached.

[00:19:28]Cognitive development is impaired. Okay.

[00:19:32]Um let me fly to treatment failure. Part of the problem with treatment failure is delayed recognition and delayed start of treatment. Okay. So early intervention is very important.

[00:19:56]The rule is seizures beget seizures. One seizure will generate another seizure.

[00:20:01]Especially we're talking unprovoked seizures. And the first two years are very critical as a window from diagnosis or from the first seizure to twoyear point is very important and um delayed treatment may create chronic epilepsy.

[00:20:23]So it's important that we respond very early to predict long-term outcomes.

[00:20:32]Even monotherapy in the first year is is important. So who is at risk for poor outcomes?

[00:20:43]So there's a cohort study that was done early life epilepsy and the data was that mortality was 2.9% in the first year, drug resistance 35% overall, 40% of infants.

[00:21:02]um less than the first year. Um developmental decline, evolution of infantile spasms, new seizures.

[00:21:12]Okay. Um predictors of drug resistance is another thing.

[00:21:18]Onset less than one year is a predictor of drug resistance. 12% plus absolute risk. Developmental delay is another predictor of drug resistance 21%.

[00:21:33]Um both factors combined 54%.

[00:21:38]The risking jumped. So predictors of developmental decline um maybe we'll read that on our own.

[00:21:48]And the clinical takeaway is younger age of onset is and developmental concerns at the onset remains a red flag for poor prognosis.

[00:22:02]So all early life epilepsies potentially pose a risk um for a troubled future.

[00:22:15]Seizures also um the case for early detection in effect and case presentation. So seizure incidents peak in the first year of life when the brain is most vulnerable up to 87%.

[00:22:29]Um okay so there's the beautiful thing is this the the presentation is fairly detailed.

[00:22:40]you will be given these presentations. Um let me just highlight a few a few more things.

[00:22:48]Um what research tells us about the single seizure a seizure event by the end of one month from your first seizure you have a cumulative recurrence rate of 20%.

[00:23:04]By 3 months that cumulative recurrence rate hits 32. by 6 months 46 by 1 year 62 3 to four years 71%.

[00:23:18]So something to not is that a single unprovoked seizure is going to go on to develop. Summarize please epilepsy. All right. Okay.

[00:23:29]So preventable mobility. The four pillars for early diagnosis is um motor vehicle accidents definitely other injuries. Um economic burden. We've already highlighted this thing. There's a cost implication to not treating epilepsy early. Seizure prognosis is dependent on when the diagnosis is made.

[00:23:53]92% of monotherapy failures occur in this window. Okay. And then early treatment prevents evolution to chronic epilepsy.

[00:24:05]Mhm. Cognitive developmental outcomes are also a problem. And then this massive treatment gap. So what is your role? What can you do today? Um screen for psychiatric co-obidities, be able to diagnose um diagnose the Okay, good. Let me just take away very good. So our parting notes um epilepsy is a spectrum. It's birectional with links to psychiatry and 30% of patients will experience depression and anxiety and 20 to 30% have non-csychoggenic um epileptic seizures. Non or psychoggenic non-epileptic seizures.

[00:25:10]Psychiatric phenomenon happen in epilepsy and some anti-seizure medications cause um side effects that are psychiatric in nature.

[00:25:23]Diagnostic delays have severe consequences and non motor seizures are primarily the cause of delayed diagnosis and the first two years are very critical for treatment. Over to you Dr. Helen will joke through the next few questions if if there are any.

[00:25:45]>> Thank you so much uh Dr. Tessa for taking us through.

[00:25:53]I I wasn't aware that there is a new classification.

[00:25:59]>> Yeah.

[00:26:00]>> May I talk to you? I was still using the 2017 >> international stepc classification but this is an eye opener to me to look up.

[00:26:11]So at this point I've taken a comments or questions. I see someone has texted that they want the presentation. I think that can be shared.

[00:26:20]I don't know if anyone has a comment or question to make basing on the presentation that uh has been delivered and put your hands up in the chat or or type on the chat and raise your hand.

[00:27:11]And there's a question coming in uh from the chat.

[00:27:16]Can alcohol use disorder cause epilepsy and what are the chances?

[00:27:22]If so, in such a case, what would the management plan look like?

[00:27:30]Probably the link between epilepsy and this. Yes. Over to you.

[00:27:35]>> Yes. So, um alcohol is an amazing substance that um does cause a lot of havoc. um all over the body, the brain being one of those. And yes, alcohol can cause um epilepsy. Usually, it is not the the type that we would expect. What typically shows up in your clinic is going to be ram fits.

[00:28:05]Somebody's either withdrawing or they have intoxicated themselves too much and then they they convulse. But a few patients do actually progress to start convulsing even when there's no al when when they're not withdrawing or being intoxicated. Um so the management would be a standard anti-epilepsy um anti-epilepsy medication.

[00:28:31]Um you could choose any of the um depending on the present presenting um symptoms of the seizure type you could choose any of the anti-epilepsy medications um available to you and um it would do do the person well yes it's not too common by the way regarding the chances it's not too common but it does happen every once in a while I have met a patient patient who who epilepsy started with alcohol.

[00:29:05]They started as ram fits but the the person quit alcohol and they continued convulsing.

[00:29:14]>> Okay.

[00:29:16]>> Thank you.

[00:29:19]Any other question?

[00:29:22]See another question. Is there duration for when one can be on the medication?

[00:29:30]I think still it's a followup question on the earlier >> maybe I'll start to take >> with the end of the question. Um by and large we would not advise you to mix alcohol with medicine. Um both alcohol and most anti-seizure medications are metabolized in the liver.

[00:29:59]and they are destructive to each other if I should put it like that. In one instance, some anti-seizure medications um are affected negatively by alcohol i.e. they reduce it reduces the concentration of the medicine in blood.

[00:30:17]Others are made toxic by increasing their concentration. So let's first deal with the basics first.

[00:30:26]quit the alcohol if not possible significantly reduce the volume consumed on a daily basis and if the person is continuing to convulse um they will need their anti-seizure medications. Those adjustments to factor in the metabolism will be needed. So they may need a bit of a higher dose depending on what anti-seizure medication you're choosing given that the liver enzymes are super active usually in people who take alcohol.

[00:31:03]Yes, >> thank you. We have another question in the chat that can uh psychoggenic non-epilept form seizures I want to assume that's the meaning turn into epilepsy if someone keeps getting them often. I think uh doctor nowadays they call them just none form seizures but you can tell us if if I think someone's wondering if someone gets this non-epilept form seizures and if it can turn into epilepsy >> no it cannot turn into epilepsy unless the person already had epilepsy or they were already at risk and for some reason or the other something happens and they get um proper proper seizures. But usually the um the psychoggenic um epilepsy psychoggenic seizures are psychoggenic in nature as you hear it. There is um a psychological reason behind this manifestation and usually the treatment is psychological in nature. CBT is the main step treatment for um psychoggenic um seizures and we advise you not to overdiagnose um or over treat the correct thing I'm trying to say is over treat or over investigate it is expensive on their pocket and you know that unnecessary medications are harmful.

[00:32:49]So the presentation will give you a few things on what you need to make sure that you you don't fall victim of over investigating non-csych or psychoggenic seizures.

[00:33:02]Um rather if you are in a setting where um there is no mental health worker refer as soon as you you are able to diagnose um this but try not to not to harm them.

[00:33:20]They need reassurance and their treatment is really um psychological in nature.

[00:33:29]>> Thank you so much Dr. Hillary. That's very clear. Um, last question cuz we we're really running out of time. I think this question is an interesting one. I don't know if we shall answer it today or in the next session. The person is ask Benjamin is asking if epilepsy patients should be treated by psychiatrists. He used the word se neurologists where should they go exactly?

[00:33:59]>> I believe Dr. Now that is yours.

[00:34:04]>> That one is yours. I hand it over to you.

[00:34:06]>> Okay. I Well, I I we can answer that even in the next session. But epilepsy primarily is a a neurological condition and the neurologists um are in the best place to treat. But in our setting as Dr. Hillary presented is that um traditionally for a very long time we did not have neurologists but also because of epilepsy being what it is um was so many psychiatric co-orbidities mentioned the stigma associated with epilepsy increases anxiety depression but also epilepsy you know the common types of epilepsy that were seen were coorbid with mental illnesses because it affects the brain so depending on the ideology of the epilepsies. Many patients presented with common mental illnesses as well. So psychiatrists have taken up that role for for a long time.

[00:35:03]But I think with growing recognition of epilepsy and recognizing epilepsy of what it is and the fact that can be treated and patients with epilepsy can receive care and remain functional. Uh there should be shared treatment because um some patients with epilepsy will have psychiatric co-obesity but we are seeing patients with purely epilepsy conditions as well without any psychiatric co-orbidities and uh physicians and pediatricians should be able to to manage. I think uh we recognize that even as as a ministry and we we have um we're making efforts to to ensure that we uh we improve uh the quality of care of patients with epilepsy because if you look at it uh Dr. I mentioned that about 30% of patients with epilepsy may have intractable seizures. That means they have other ideologies and there are other forms of treatment like deep brain stimulation or lobectomy depending on the condition or the cause of of the epilepsy that should be explored. But if we continue to provide care as is, we might not uh provide this we may not adequately explore all these other modes of care. So I think it's it's that time that we start to to sit together as different disciplines and then we harmonize to improve the quality of care and also the quality of life of patients living with the eclipse. So with that I I hope I answered it right Dr. Hillary. This this wasn't my session.

[00:36:45]>> I hijacked you. Thank you so much. I I do believe you have done it done the question justice.

[00:36:52]Okay. So I want to hand over now. I think we've we've short over time. I really want to appreciate you Dr. Hill for sparing some time to taking us through. As uh Dr. Lilian mentioned that this is one of two um two two sessions.

[00:37:10]So we shall have another session after two weeks. This will come through as a follow up on on on this session that Dr. Tessa has just presented. I think the next session will focus mostly on on treatment and so as we've identified we go on to treat. So I want to encourage you to join in again those that have spared some time to join. Thank you so much and again we want to appreciate uh microlabs for for hosting us in in this session. I hope learning has taken place.

[00:37:44]Um I hand over to Dr. Liian to close us.

[00:37:48]Dr. Thank you very much Drs. Khalani and Fessa for this very insightful and educative session.

[00:38:00]Unfortunately, our time is not so much.

[00:38:03]So, it's very hard for someone to really talk about everything that we really need to know. However, thank you so much for educating us, Dr. Octessa. Our next session is on Monday next week. These sessions are going to be happening every second and third week of the month. That is Monday. Every second Monday and third Monday of the month. Uh so next Monday 700 p.m. we shall be talking management of epilepsy and available drugs on the market. So all the people who are asking questions regarding management, please tune in next Monday.

[00:38:41]Otherwise, thank you Microlabs. Thank you everyone for creating the time. Have a good evening.

[00:38:50]>> Thank you. Good evening too.

[00:38:54]Thank you doctors.