Epilepsy is a brain disorder characterized by a persistent predisposition causing epileptic seizures. Epileptic seizures occur suddenly and can cause a variety of symptoms, including unusual physical symptoms and altered consciousness, movement, and sensation associated with brain localization. However, the general understanding of epileptic seizures is that it results in loss of consciousness and generalized convulsion, and when there are other symptoms, there are many cases in which misdiagnosis as a mental illness/symptom is sometimes made. Cases with a chief complaint like a seizure suspected of being mental illness are introduced to the general hospital psychiatry from other departments. Although these are seemingly difficult differentiations, if the features of epileptic seizures are visible, a differential diagnosis can be made even without an accurate the EEG reading. In this article, we also present actual cases and explain the epileptic seizures that are easily misdiagnosed as mental illness and symptoms of mental illness.

Patients with epilepsy (PWE) have a high prevalence rate of psychiatric comorbid disorders compared with the general population. Psychiatric comorbid disorders among PWE involve depression, anxiety, psychotic, insomnia and attention-deficit disorders etc. They are very diverse at the pathological level, and therefore there is complexity in diagnosis and treatment. To understand the psychiatric comorbid disorders among PWE, they are historically classified by time interval based on psychiatric symptom onset to epileptic seizure, to ‘peri ictal’ and ‘inter ictal’. Recent anti-epileptic drugs having psychiatric side effects add further complexity. In addition, psychiatric comorbid disorders have higher impact on the PWE’s quality of life than their epileptic seizures. By this complexity and high impact, psychiatrists still should play important roles in the epilepsy treatment. However, currently, neurologists are intensely involved to epilepsy treatment activity and psychiatrists are merely involved. Due to this condition, the necessity of increasing the number psychiatric epileptologists and getting them involved in the epilepsy treatment activity needs to be emphasized. In this session, psychiatric comorbid disorders among PWE are reviewed highlighting the necessity of psychiatric epileptologists in epilepsy clinical contexts.

Epilepsy is most likely to develop in later life. Making a secure diagnosis can be challenging because the clinical manifestations of seizures and the differential diagnoses and causes of epilepsy can be different in older individuals compared with younger individuals. In practice, common causes that should be specifically considered in patients with late-onset epilepsy include cerebrovascular disease, primary neurodegenerative disorders associated with cognitive impairment (particularly Alzheimer’s disease). The most common type of epilepsy in elderly people is focal seizures with impaired awareness, the characteristic seizure’s symptoms are Non-convulsive status epilepticus, transient epileptic amnesia and long postictal confusion period. Elderly people are more likely to have comorbidities, particularly cerebrovascular disease and dementia, which all require recognition, evaluation, and management. Additionally, age-associated physiological changes can affect the pharmacokinetics and pharmacodynamics of antiepileptic drugs.

Psychogenic nonepileptic seizures (PNES) are similar to epileptic seizures. For their management, antiepileptic drugs are ineffective, while psychiatric treatment is effective. The diagnosis and treatment of PNES should be seamlessly linked through the establishment of a comprehensive PNES care system, and psychiatrists are expected to play a central role in this process. The knowledge of general hospital psychiatry may be utilized in various collaborations, such as the following: 1) Collaboration with epileptologists in communicating the diagnosis of PNES, making a significant shift from epilepsy care to psychiatric care, and facilitating access to psychiatric treatments. 2) Establishing an emergency treatment system for PNES patients, with emergency physicians. 3) Analyzing the biological, psychological, and social problems in the patient’s background and providing environmental modification and cognitive behavioral therapy-based psychiatric care with a multidisciplinary team. 4) Referring the patient to specialists with advanced psychotherapy and providing continuous support.

Background: With the aim to improve preventive interventions for delirium, delirium assessment by nurses, and nursing care, the “Nurse-centered delirium care program,” created by a head ward nurse and Certified Nurse Specialists in Psychiatric Mental Health Nursing was implemented in the Department of Gastroenterology and Endocrinology ward, and the usefulness of the program was examined. Methods: We compared delirium onset rates between the program pre-implementation group (May through July 2016) and post-implementation group (July through September 2017) using Chi-square analysis. Delirium onset was determined according to ICD-10 diagnostic criteria. To examine the usefulness and challenges of the “Delirium assessment flowchart,” which is an integral part of the program, we conducted a questionnaire survey targeting nurses in the ward. We calculated the frequency of the scores for each question item and performed qualitative analysis of the reasons for the scores. Results: Comparison of delirium onset rates between the two groups revealed that delirium onset was noted in 36/339 of the program pre-implementation group and in 23/359 of the post-implementation group, showing a significant decrease in delirium onset with program implementation (χ² (1)=3.999, p<.05). In the questionnaire survey, 80% of nurses reported that the flowchart was useful in delirium assessment and care ([able to perform the anticipated observations/care], [useful for screening and assessment]), 80% reported that their workload had been increased, and 71% reported that they should continue to use the flowchart. Conclusions: The nurse-centered delirium care program was suggested to be useful in the preventive intervention of delirium to achieve reduced onset rates, as well as in improving nurses’ delirium assessment capability and nursing care. However, considering the degree of work burden sensed by nurses, we need to evaluate how we might lessen their burden in the future.

BACKGROUND: The actual situation regarding the use of seclusion and restraints in Japanese psychiatric hospitals remains mostly elusive. OBJECTIVE: To elucidate the characteristics of patients who have been subjected to seclusion and restraints and the reasons for the use and duration of the techniques performed under clinical contexts. METHODS: A comprehensive review of electronic health records at a single-center stand-alone psychiatric hospital was performed, investigating the content of seclusion and restraint orders initiated between October 2018 and September 2019. RESULTS: A total of 1389 orders of restrictive measures were reviewed, resulting in 1083 orders (390 seclusions, 693 restraints) for final analysis. These orders corresponded to 363 patients, with nearly half diagnosed with schizophrenia (n=177, 49%) and the next most frequent diagnosis being dementia (n=53, 15%). Reasons for seclusion included "worrisome course," "self-harm," and "excitement and agitation," while "falls and wandering" and "medical treatment" were typically selected as reasons for restraint orders. The number of restrictive measures ordered per patient was three on average and 41 at maximum. The total duration of restrictive measures performed per patient was 213 (92–569) hours in the median and interquartile ranges, with the maximum being 8478 hours. CONCLUSION: It was a notable finding that restraints were administered for less than 24 hours in nearly half of the patients. The ethical legitimacy of the duration in which restrictive measures were in place was demonstrated.

The researchers interviewed a middle-aged male patient with autism spectrum disorder (ASD) concerning his experience with autism spectrum disorder and analyzed the interview data phenomenologically. Despite receiving psychiatry to treat his ASD, he did not mention “ASD” but instead discussed difficulties in bodily movement, a long-term decrease in physical strength, and his mental anxiety. These topics may be indicative of his expectations regarding psychiatric therapy. The data analysis showed that he did not perceive the difficulties he faced in the workplace and his deteriorated condition as having a causal relationship, but he viewed each simply as a perceived fact. In addition, he said “It seems there are few complaints (in me)” instead of “I have no complaints.” Although such wording sounds strange, it is rather true to the logic of experience. It is indicative of the absence of perceived complaint after a reflection. These findings suggest that there might be other patients with ASD whose experiences do not include the results of inferences beyond their direct perception.

Clozapine may be discontinued due to neutropenia, but there is a lack of evidence for treatment of neutropenia other than lithium carbonate. This case report describes a treatment of neutropenia with lithium carbonate, adenine, and alkaloids extracted from Stephaura cepharantha Hayata (cepharanthine). A young woman with a diagnosis of treatment-refractory schizophrenia had stable psychotic symptoms following treatment with clozapine. She already had a relatively low neutrophil count (2300/μL) before she started clozapine. She had been treated with lithium carbonate for mild neutropenia after starting clozapine, but she had to stop clozapine because her neutrophil count had dropped to 1800/μL. Her psychosis also worsened markedly. After treatment with several antipsychotics and modified electroconvulsive therapy with no improvement, clozapine was started again. When lithium carbonate, adenine, and cepharanthine were used in combination with clozapine to prevent neutropenia, neutrophils did not drop below 2500/μL, and continued use of clozapine improved psychotic symptoms. This report suggests that not only lithium carbonate, but also adenine and cepharanthine are effective for clozapine-induced neutropenia.