Transcript Hardy Paul Toronto 2009

Epilepsy in Autism: An
Overview
Autism One Conference
Toronto, Canada
Oct. – Nov. 2009
www.hardyhealthcare.com
[email protected]
781-740-8300
Nov. 09
HHA
1
A Time for Optimism
32 year perspective
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Back wards of a 1300
bed state school for
the MR
Began to suspect
complex partial szs
If not on EEG, do not
rx.
Rigidity of thinking is
changing.
Nov. 09
HHA
2
An Integrative Approach
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Attention to diets and nutrition
Attention to environmental factors
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Vaccines
Mercury
Attention to allergies, oxidative stress,
inflammation, and detoxification
Nov. 09
HHA
3
Epidemiology is Different in Autism
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Incidence of epilepsy is higher in autism
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Abnormal EEGs – up to 84%
Higher incidence of vaccination-induced
seizures:
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M. Rutter in 1970 stated @ one third
20% to 40% is current estimate
Pertussis, etc.
Higher incidence of temporal lobe seizure
(TLE or CPS)
Nov. 09
HHA
4
Morbidity is Increased
• Impaired or delayed language
• Impaired or delayed cognition
• Secondary emotional symptoms
Anxiety, fear, obsessionalism
• Social impairments
Helmets, unable to swim at times
• Anxiety in parents and staff of programs
Nov. 09
HHA
5
Look for Comorbidity
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Co-morbid diseases
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Tuberous Sclerosis
Fragile-X syndrome
Mesial-temporal sclerosis
Rubella
Neruo-inflammatory conditions?
Mitochondrial disorders
Unrecognized nutritional or metabolic
issues: functional folic acid deficiency
Neuro-toxins: heavy metals?, etc.
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Nov. 09
HHA
6
Mortality: Increased
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Few studies on this subject (? avoidance)
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Nov. 09
SIDS
Sudden Unexplained Death in Epilepsy
(SUDEP)
Cardio-respiratory event
Early morning nocturnal seizures
Aspiration
Trauma
Drowning
HHA
7
Diagnosis: More Difficult
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Often non-verbal or limited ability to
express symptom, especially emotional
feelings
Often unable to cooperate for EEGs,
BEAMs, QEEGs, MEGs
Seizure vs: inattention, tics, Sydenham’s
chorea, ‘stereotypy of autism’, PANDAS
Subclinical discharges & occult szs
Nov. 09
HHA
8
Clinical History is Key!
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Temporal and paroxysmal patterns
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Trauma: birth or other head traumas
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History, history, history
Location, location, location
Mesial-temporal sclerosis
Constellation of symptoms and signs
Family history of variable importance
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Nov. 09
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Myoclonic epilepsy
Mitochondrial disorders
HHA
9
Examination
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Neurocutaneous disorders
Dysmorphic features suggestive
of chromosomal disorder or
genetic disorder
Fetal alcohol syndrome
Valproate syndrome
Nov. 09
HHA
10
Laboratory Testing
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Neurophysiologic
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Sensitivity and specificity
Imaging studies
Genetic
Metabolic
Toxicological
Oxidative stress, sulfation, methylation
The Therapeutic Trial
Nov. 09
HHA
11
Basic Adage
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“If you do not know the diagnosis
after taking the history and doing
the exam, go back and take the
history over again.”
 Robert Joynt, MD, PhD.
Nov. 09
HHA
12
Epilepsy Classification
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Generalized (both hemispheres involved)
 Tonic-clonic (Grand Mal, major motor)
 Petite Mal (Absence seizure)
Partial
 Simple: one modality of brain function
 Complex: two or more
 Temporal Lobe Epilepsy
 Secondary Generalization
Myoclonic Epilepsy.
Nov. 09
HHA
13
Special Syndromes in ASD
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TLE: + Panic Disorder +/- OCD
Landau-Kleffner Syndrome (epileptic
aphasia): role of inflammation or
oxidative stress?
Post Vaccination Epilepsy
Cerebral Folate Deficiency
Nov. 09
HHA
14
Nov. 09
HHA
15
Travolta Case
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Kawasaki’s Disease – mucocutaneous lymph node
syndrome “not associated with either autism or
epilepsy”.
BUT note the signs and symptoms of KD:
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Nov. 09
High fever lasting for five days or longer
Pinkeye in both eyes
Redness of lips, tongue, and lining of mouth
Swollen cervical lymph node > 1.5 mm in diameter
Red rash on the body, which may be flat or bumpy and that may
have variable pattern
Swollen hands and feet with redness of palm and soles. In
second week there may be peeling of the skin starting around
the fingernails and moving up the arms
HHA
16
Kawasaki’s Disease, Acrodynia,
and Mercury
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Mercury may play a pathogenic role
High urine mercury
Overlap of symptoms in two syndromes
Genetic depletion of glutathione S-transferase
Onset often within days of vaccination
1985 – 1997 20x in incidence, paralleling use of
thimerosal
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Nov. 09
Mutter J & Yeter D. Curr Med Chem. 2008;
15(28):3000-10.
HHA
17
Pre-ictal
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The build up of tension/agitation
Deepening of mood or depression
Increase of anxiety
Heightening of mania or obsessions and
compulsions
Exacerbation of psychosis
Therapeutic effect of seizures
Nov. 09
HHA
18
Partial Ictal Phenomena
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Motor Symptoms
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Focal motor activity
anywhere on body
Speech arrest
Somato-sensory and
Special Sensory
Hallucinations
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Nov. 09
HHA
Somato-sensory
Unformed visual
Olfactory
Gustatory
Vertiginous-vestibular
19
Partial Ictal Phenomena,
Continued
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Psychic-Cognitive
Symptoms
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Fear, Anxiety, Panic
Depression
Anger
Irritability
Pleasure
Dysphasia
Deja vu
Jamais vu
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Nov. 09
Derealization
Speeding thoughts
Incoherence of thought
Distortions of:
HHA
Time
Body Image
Odor
Sound
Color
Size, shape, distance
Hallucinations
Mystical experience
20
Partial Ictal Phenomena,
Continued
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Autonomic Symptoms
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Nov. 09
Abdominal: nausea
Chest
Unusual head
Hyper-salivation
Diaphoresis
Temperature
Pallor or flushing
Piloerection
Palpitations
HHA
21
Post-ictal
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Aggression
Self-injury
Confusion, Delirium
Lethargy, Anergy, Somulence
Nov. 09
HHA
22
Interictal
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Aggression
Psychosis (Schizophreniform)
Sexual Dysfunction
Religiosity and Philosophic Interests
Hypergraphia
Circumstantiality and Viscosity
(“stickiness”)
Nov. 09
HHA
23
Interictal Period
“The Epileptic Personality”
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Obsessiveness
Viscosity
Emotionality
Circumstantiality
Paranoia
Depression
Altered Sexual
Interest
Nov. 09
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HHA
Anger
Aggression
Dependence
Religiosity
Hypermorality
Increased
philosophic Concerns
24
TLE & Panic Attacks & SIB
Temporal Lobe
Epilepsy
Panic Disorder
Nov. 09
HHA
25
TLE & Panic and SIB
Nov. 09
HHA
HHA
26
Biomedical Interventions
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NUTRICEUTICAL
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HORMONAL
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Natural progesteron
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Be careful of synthetic progestins & Provera
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PHARMACEUTICAL
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NEUROFEEDBACK
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DETOXIFICATION: +/- CHELATION
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VAGUS NERVE STIMULATION
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NEUROSURGERY
Nov. 09
HHA
27
Treatment Should Be Iterative
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“Trial and
Error”
“Willing to stick
one’s neck
out” - to be
inventive
Nov. 09
HHA
28
Coups in Boston 
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7 y/o girl with spikes on EEG, absent AER,
probable regressive autism, side effects from
Depakote (sedation) and Lamictal (rash), and
fear of trying prednisone due to side effects: “I
told her (mother) that I am more inclined to think
that the treatments which Dr. Hardy may
prescribe might actually do more for her and be
safer in the long run. Thus, I thought it made a
lot more sense to pursue that route first.”
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Nov. 09
David L. Coulter, M. D., Harvard Medical School, December
2008
HHA
29
Nutritional/Natural Treatments I
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Diets
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Ketogenic (since 1921)
Atkins Diet?
Casein-free and/or gluten-free
Hormonal
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Natural progesterone
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Nov. 09
Pills
Lozenge
Creams (ProGest)
HHA
30
Nutritional/Natural Treatments II
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L-Carnitine (to prevent valproate toxicity)
Magnesium (pre-eclampsia)
Zinc
Omega-3 EFAs
Vitamin B6 as P-5-P
L-methylfolinic acid: Deplin &
CerefolinNAC
Nov. 09
HHA
31
Nutritional/Natural Treatments III
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Mitochondrial cocktails
Vitamins D, E, thiamine, biotin, B12
Manganese
DMG and/or TMG
Sulfur as ALA, glutathione, MSM, DMSA
Nov. 09
HHA
32
Antiepileptic Medication I
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First Generation (1930 – 1980) – all associated
with side effects (especially folate deficiency)
and adverse drug-drug interactions
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Nov. 09
Bromides
Barbituates
Phenytoin
Carbamazepine
Valproic acids
ACTH & steroids
HHA
33
Antiepileptic Medication II
Second generation (1990 – 2002) - fewer side effects
 Neurontin
 Lamictal
 Topamax
 Gabatril
 Zonagran
 Keppra – “The B6 discovery!”
 Lyrica
Nov. 09
HHA
34
The B6 Discovery 
• Vit B6 found to reduce behavioral side
effects from Keppra
Nov. 09
HHA
35
Antiepileptic Medication III
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Third generation in phase 3 Trials (2009 – ?)
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Nov. 09
Carisbamate
Retigabine
Eslicarbazepine
Lacosamide
HHA
36
Vagal Nerve Stimulation
Nov. 09
HHA
37
Vagal Nerve Stimulation
Nov. 09
HHA
38
Questions
Nov. 09
HHA
39