EEG in psychiatry

[Psychferlyfe3000]

I came across a paper recently with over 1000 treatment-refractory psychiatric patients (3 med trial failures) that showed that roughly half of them had EEG abnormalities of one of 4 categories: focal slowing, spindling excessive beta, encephalopathy, and isolated epileptiform discharges. Is this as novel or useful of a finding as I think it is or can this easily be explained away with pre-existing knowledge?

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[Psychferlyfe3000]

"Evidentiary Significance of Routine EEG in Refractory Cases: A Paradigm Shift in Psychiatry"

 

[futureapppsy2]

How would you use this clinically?

 

[splik]

This is a poor man's amen clinic. The lead author is a social worker who "holds the distinction of being the first integrate Pharmaco-EEG into private practice in the United States." [sic]

Also, psychotropic medications frequently cause EEG abnormalities and most of these patients were on multiple psychotropics. EEG is under-utilized but I don't think this paper tells us anything useful.

 

[thelastpsych]

This is a poor man's amen clinic. The lead author is a social worker who "holds the distinction of being the first integrate Pharmaco-EEG into private practice in the United States." [sic]

Also, psychotropic medications frequently cause EEG abnormalities and most of these patients were on multiple psychotropics. EEG is under-utilized but I don't think this paper tells us anything useful.

When do you think EEGs should be utilized as a psychiatrist?

 

[splik]

When do you think EEGs should be utilized as a psychiatrist?

I used to order them, I'm no longer able as the 2 ivory towers near me don't allow it anymore. I think the answer is very rarely in general psych and semi-rarely in neuropsych or liaison psych. EEG referrals from psychiatry have the lowest hit rate. However if you are thinking about frontal lobe seizures, temporal lobe seizures, non-convulsive status epilepticus, delirium/encephalopathy, then it is worth considering. Can be helpful in some cases in distinguishing dissociative disorders from encephalopathic or epileptic conditions, and in some cases in distinguishing functional cognitive disorders from coarse brain disease. I've actually had a few pts who were referred to me for anxiety who were actually having seizures. In one case the referral came from an epileptologist! of course, an EEG is not needed to dx seizures but can be helpful in some cases.

I can tell you that they can be helpful on C-L is assisting distinguishing delirium from primary psychiatric disorder. Makes it harder for the team to claim this is psych when the EEG shows triphasic waves (although they might still try!) The problem is the sensitivity of a spot EEG is not great for delirium, nor for epilepsy.

 

[Merovinge]

I used to order them, I'm no longer able as the 2 ivory towers near me don't allow it anymore. I think the answer is very rarely in general psych and semi-rarely in neuropsych or liaison psych. EEG referrals from psychiatry have the lowest hit rate. However if you are thinking about frontal lobe seizures, temporal lobe seizures, non-convulsive status epilepticus, delirium/encephalopathy, then it is worth considering. Can be helpful in some cases in distinguishing dissociative disorders from encephalopathic or epileptic conditions, and in some cases in distinguishing functional cognitive disorders from coarse brain disease. I've actually had a few pts who were referred to me for anxiety who were actually having seizures. In one case the referral came from an epileptologist! of course, an EEG is not needed to dx seizures but can be helpful in some cases.

I can tell you that they can be helpful on C-L is assisting distinguishing delirium from primary psychiatric disorder. Makes it harder for the team to claim this is psych when the EEG shows triphasic waves (although they might still try!) The problem is the sensitivity of a spot EEG is not great for delirium, nor for epilepsy.

Thank God you expanded on that exactly how a neuropsychiatrist would, rather than leave it open ended where people might be thinking you thought they were going to guide psychotropic usage 🤣. I miss getting EKGs on neuropsych c/l and regular c/l.

 

[mistafab]

I have used EEG in c/l settings. Mostly it is someone who is presenting as psychotic with history of seizures. Everyone is saying "they aren't seizing, they are psychotic" and are on their AEDs. I push them saying it is extremely atypical for psychosis to develop floridly in a matter of 1-2 days if they are not intoxicated. They push back saying it is probably schizophrenia or bipolar.

Instead of starting an antipsychotic, you make a stink that they should get an EEG. Lo and behold... they are seizing.

Not really many use cases for me outside of the rare seizure as psychosis presentations, or TLE. Most deliriums or catatonias will give you "generalized slowing" which isn't very useful clinically.

 

[comp1]

Concur with the above saying that you would use EEGs extremely rarely. Certainly the non-specific things the OP described are not helpful. I also don't think you can diagnose "encephalopathy" from an EEG. Even with frank epileptiform activity (which is vanishingly rare already), medicine is still going to push for a primary psych diagnosis (and transfer please) regardless.

 

[romanticscience]

I was tempted to buy myself EEG equipment after going down this rabbit hole:

Brain arousal regulation as response predictor for antidepressant therapy in major depression - Scientific Reports

A tonically high level of brain arousal and its hyperstable regulation is supposed to be a pathogenic factor in major depression. Preclinical studies indicate that most antidepressants may counteract this dysregulation. Therefore, it was hypothesized that responders to antidepressants show a) a...

www.nature.com

I deferred because I didn't want to be considered my city's Dr. Amen.

 

[Psychferlyfe3000]

Here is a more developed example of utility of EEG: The role of the electroencephalogram (EEG) in determining the aetiology of catatonia: a systematic review and meta-analysis of diagnostic test accuracy​

 

[Psychferlyfe3000]

Also this is an interesting review article that highlights that the potential of isolated epileptiform activity is far from ruled out:

Inhibiting epileptiform activity in cognitive disorders: possibilities for a novel therapeutic approach​

 

[splik]

On a more positive note, we are making strides with doing EEGs on cats using knitted hats! (see: https://www.sciencedirect.com/science/article/pii/S0165027024001997)

 

[clausewitz2]

On a more positive note, we are making strides with doing EEGs on cats using knitted hats! (see: https://www.sciencedirect.com/science/article/pii/S0165027024001997)
View attachment 393356

Combine all the quackery, write ESA letters for fEEG cats

 

[Psychferlyfe3000]

I, for one, find those papers quite uplifting, hahaha. The cat is pretty cool too though #science.

 

[calvnandhobbs68]

I, for one, find those papers quite uplifting, hahaha. The cat is pretty cool too though #science.

Why exactly do you find them uplifting? Can you expound on this somehow?

 

[Psychferlyfe3000]

Because so little has been done when it comes to isolated epileptiform activity. These are raw signals with good signal-to-noise ratio (relative to qEEG). If you look at the better-developed epilepsy literature on this topic, you can see that eg inter-ictal discharges actually do impact various domains of cognitive functioning depending on where they occur in the cerebral cortex and how frequently they occur. We don't really know if the same is true or not for psychiatric disorders that don't involve seizures but still are associated with increased isolated epileptiform activity. Additionally, we are now finding that there are even some limbic epileptiform discharges (small sharp spikes from the hippocampus) that are visible during sleep on EEG. These are associated with eg impulsivity and suicidality and seen eg at high rates in eg bipolar patients. It is all extraordinarily preliminary though compared to the qEEG literature, but I think there is a lot of potential here. That's my take anywway.