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Electroencephalograph

y
In Psychiatry
Introduction

Electroencephalography (EEG) is an important, non-


invasive functional method for the investigation of
electrical activity in the brain.

Very useful tool in the differential diagnosis of psychiatric


and/or neurological presentations.

It can also be useful for monitoring and helping to


evaluate the clinical or therapeutic course of psychiatric
disorders and to guide treatment plans.
Introduction

espite the fact that !e have had the ability to record


brain electrical potential since "#$% and that this !or&
!as spearheaded by r 'erger, a psychiatrist, to this day
the significance of some EEG changes present in
psychiatric patients remains poorly understood.
(cope of the presentation

)istory.

EEG in *sychiatry.

*hysiology behind EEG.

EEG +ecording and ,nalysis.

EEG (ignals.

-ormal EEG patterns.

,bnormal EEG patterns.

EEG in *sychiatry.
HISTORY

+ichard .aton -

*rofessor of *hysiology, !as the first to document the


e/istence of electrical potentials emanating from the
brains of live animals.

,dolf 'ec& -

0as able to sho! that the visual corte/ of the dog


produced large electrical potentials !hen the animal1s
eyes !ere rhythmically illuminated.
HISTORY

)ans 'erger -

2irst non-invasive scalp EEG recordings from humans


and coined the term EEG and described the alpha !ave.

2rederic Gibbs -

sho!ed that high-voltage discharges in the brain !ere


produced !hen the animals !ere thro!n into sei3ures by
administering convulsive drugs.

0idely regarded the true father of clinical EEG.


Early uses

Epilepsy.

(tructural lesions.

)ead trauma.

Encephalopathies.

4p until the introduction of .5 scans, EEG referral for


suspected tumour !as an accepted part of psychiatric
practice.
Physiologic Basis of the
EEG Signal

5he EEG is the recording of the spontaneous electrical


activity generated by cerebral neurons.

epolarita3ion, repolari3ation and the role of intracellular


ions.

E/citatory and inhibitory postsynaptic potentials


Brain structures involved in the genesis of
EEG rhythms
EEG Recording and Analysis

EEG devices - consist of an electrode board !ith a set of


separate channels (!ith preamplifiers, filters) connected
to electrodes placed on the scalp and receiving the
electrical signals via these electrodes.

5he number of electrodes is relevant for the reliability of


the EEG signals in terms of locali3ation.

6inimum eight to t!elve electrodes, research


laboratories often use more than 7% channels.
(tandard electrodes

.onsist of flat metal discs made of silver, gold or tin,


connected to a !ire.

,ttached to the scalp according to a standardised system


("8-$8 system).

2luid substances (electrode paste, collodion, alcohol,


etc.) are used to improve contact !ith the s&in and
conductivity and reduce impedance.

.onnected to the EEG amplifier via shielded !ire and the


electrode board.
Technical requirements

ifferential amplifying techni9ue to differentiate and


suppress un!anted e/trinsic signals.

)igh- and lo!-pass filters that can be ad:usted


separately. .ommon settings are high-pass filters of 8.;
)3 and lo!-pass filters of <8 )3 to suppress or eliminate
activity belo! 8.; )3 or above <8 )3.

-otch filters eliminate the ;8 or 78 )3 cycle artefacts..


Electrode placement:
International !"#! System

"8-$8 - *ercentage of the distance bet!een neighbouring


electrodes relative to the distance bet!een beginning and
end of a ro!, for e/ample the midline bet!een nasion and
inion, the circumference above eyebro!s and ears, or the
coronal electrodes bet!een left and right earlobes.
International !"#! System
Electrode placement:
International !"#! System

Each electrode has an identifying name !ith a letter


indicating the general area.

. = central, * = parietal, 5 = temporal, > = occipital, , =


earlobes .

>dd numbers on the left and the even numbers on the


right. ?@s on the midline.


$ontages

EEG signals reflect the recording and amplification of


brain electrical potentials that are different bet!een t!o
electrode sites.

+eferential montage - connects each of the (Aactive1)


electrodes !ith the same single reference (Ainactive1)
electrode, ideally a!ay from the scalp.

'ipolar montage is used to investigate differences


bet!een Aactive1 scalp electrodes, !hich are connected
!ith each other and t!o active neighboring electrodes.
$ontages

EEG signals reflect the recording and amplification of


brain electrical potentials that are different bet!een t!o
electrode sites.

+eferential montage - connects each of the (Aactive1)


electrodes !ith the same single reference (Ainactive1)
electrode, ideally a!ay from the scalp.

'ipolar montage is used to investigate differences


bet!een Aactive1 scalp electrodes, !hich are connected
!ith each other and t!o active neighboring electrodes.
,dvantages and disadvantages.

+eference montages - often useful in cases of general


alterations e/cluding the reference electrode.

isadvantage - pic& up a great deal of physical


movement, muscle and electrocardiographic artefacts.

'ipolar montages - are more suited for the detection of


focal disturbances generalised changes.
EEG recordings

Buiet, sound attenuated, electrically sheilded


environment.

(ub:ects are seated in a comfortable reclining chair !ith


eyes closed !hile being in a !a&eful resting state.

(hould last for at least C8 minutes, including reactivity


tests and activation.

.linical observations.

,rtifacts
EEG signals

'rain activity consists of rhythmical signals (rhythms)


traditionally divided into fre9uency based categories.
EEG signals

5he presentation of specific EEG rhythms depends on


age, !a&efulness and other conditions.

5he dominant or most prominent fre9uency !ith a clear


suppression upon eye opening is called the bac&ground
rhythm.

In adults (!a&eful resting condition) this bac&ground


rhythm is !ithin the alpha fre9uency band, usually D="8/s
EEG signals % Artifacts

'iological ,rtifacts -
6uscle activity, electrocardiogram, lid movements, eye
movements, !et s&in, body movements, tongue
movements.

5echnical ,rtifacts -
efective electrodes, !ires, electrostatic disturbances,
electromagnetic interference, ;8h3-78h3 po!er sources.
,lpha rhythm

6ost prominent feature of the normal mature EEG, and


related to cerebral blood flo!
2re9uency - D-"$ )3
Eocation - *osterior dominant , may be a little more anterior, may
be more !idespread
6orphology - +hythmic, regular, and !a/ing and !aning,
rounded typical spindle shape.
,mplitude - Generally $8-"88 mV
+eactivity - 'est seen !ith eyes closedF attenuates !ith eye
opening and sensory stimuli.
Beta Rhythm
2re9uency G"C )3 - .ommon "D-$; )3, less common "%-"7 )3,
and rare C;-%8 )3
Eocation - frontocentral but variable = % subtypes
6orphology - 4sually rhythmic, !a/ing and !aning, and symmetric
,mplitude - 4sually range of ;-$8 mV
+eactivity - stages I and II sleep and decreased during deeper
sleep stages. (attenuates) to voluntary movements and
proprioceptive stimuli.
Beta Rhythm
,bsence of beta activity is not abnormal. >n the
other hand asymmetrical beta or the absence on
one side or one location !ould be indicative of an
abnormality !here beta is not being produced.
Rhythm

2re9uency of <-"" )3

Eocation - .entroparietal area, ma/imum over cC,c%

6orphology - ,rchli&e shape or li&e an HmHF most often


asymmetric and asynchronous bet!een the $ sides may
be unilateral

,mplitude - comparable to that of the alpha rhythm

+eactivity - attenuates !ith contralateral e/tremity


movement, the thought of a movement, or tactile
stimulation, does not react to eye opening .
5heta activity

2re9uency of %-<.; )3

Eocation = *osterior temporal and frontal areas

,mplitude - Intermittent 7 to < )3 theta of less than "; IV


has been reported in C;J of normal young adults during
rela/ed !a&efulness

+eactivity - 6ental calculation and intensive thin&ing.


Gamma activity

5he fre9uency range of gamma band is bet!een C8 and


<8 )3, usually centered around %8 )3.

5he gamma oscillations have been classified into


induced, evo&ed, emitted and spontaneous .

*robing of gamma activity has proven of great interest in


the field of 9uantified EEG.

5he resolution of EEG does not allo! the na&ed eye to


e/amine this fre9uency range in a clinically useful
manner.
Eambda !aves

Eocation = >ccipital region

,mplitude = belo! ;8IV

+eactivity - Visual e/ploration.

(ometimes asymmetric, !ith higher amplitudes than


the rest of posterior dominant rhythm. It is useful to
place a plain !hite sheet of paper in front of the
individual, eliminating the visual input to differentiate
from epileptiform discharges.
elta activity

2re9uency of less than %)3.

+eactivity - they are seen at the onset of dro!siness, in


deep sleep, in response to hyperventilation or induced by
psychotropic drugs in adults.

'oth delta and theta activities are related to cerebral


blood flo!, increasing !hen the cerebral perfusion is
reduced.
Activation procedures

,ctivation procedures are aimed at inducing epileptic and


non-epileptic pathological patterns.

5he most commonly used activating procedures are

)yperventilation -5he hypocapnia causes mild cerebral


vessel vasoconstriction and, hence, mild cerebral
hypo/ia.

Intermittent photic stimulation - alternating flashes


varying from " to C; )3 by means of a
stroboscopicstimulator placed " metre from the
sub:ect1s eyes

(leep deprivation - &eeping the sub:ect a!a&e all or


part of the night before recording an EEG
Physiological modifications
induced &y activation
procedures
)yperventilation 'ilateral increase of slo!
!aves resolving !ithin $
minutes after
hyperventilation.
= Induction of alpha rhythm
in sub:ects !ith lo!-voltage
EEG.
Intermittent photic
stimulation
*hotic drivingK production of
rhythmic potentials
time-loc&ed to the fre9uency
of stimulation, prevalent
over the occipital leads.
(leep deprivation
*eriods of dro!siness or
sleep.
EEG patterns in normal ageing
-slo!er fre9uencies of alpha activity !ith a reduction of "
)3 every "8 years after the age of ;8 years but never
belo! D )3.
-slight reduction in amplitude, a reduced percentage of time
in !hich alpha is present and a reduced reactivity.
-, reduced slo! response to hyperventilation has been
reported in normal elderly sub:ects !ith respect to young
adults.
EEG patterns in normal ageing

Llass and 'renner - benign temporal delta transients of


the elderly.

(a) occurrence after 78

(b) confined over the temporal regions

(c) higher prevalence on the left side

(d) absence of bac&ground abnormalities and of abnormal


asymmetries ofthe alpha rhythmF

(e) rounded morphology

(f) voltage usually <78=<8 IV


EEG patterns in normal ageing

Llass and 'renner - benign temporal delta transients of


the elderly.

(g) reactivity consisting of an attenuation during mental


alerting and eyes opening and increase !ithdro!siness
and hyperventilation.

(h) occurrence sporadically as single !aves or in pairs,

not in longer rhythmic trains.

(i) present only for a very small proportion.


'nusual EEG patterns

-on-controversial EEG patterns - 5hey refer to rhythmic


or epileptiform !aveforms that are rare or unusual but
!ithout &no!n clinical significance.
'nusual EEG patterns

(ontroversial EEG patterns

-5hey tend to be more represented in psychiatric


populations, in general they do not indicate a sei3ure
disorder, and the clinical correlates tend to be vague as in
neurovegetative symptoms.

-5he controversial label.


+hythmic mid-temporal
ischarges (temporal theta
bursts of dro!siness or
psychomotor variant)
'ursts of rhythmic theta !aves
lasting longer than "8 sec, !ith
variable
morphologies, but more often
sharply
contoured, occurring over the
midtemporal leads during rela/ed
!a&efulness and dro!siness.
*ositive bursts of "% and 7
)3 (ctenoids)
'ursts of rhythmic arciform !aves
lasting 8.;="sec, usually unilateral
or bilaterally asynchronous. 5he
t!o fre9uencies are intert!ined,
!ith the
"% )3 fre9uency more prevalent.
*revalent in children and
adolescents.
(mall sharp spi&es or (((
of sleep (benign
epileptiform transients of
sleep)
6onophasic or diphasic spi&es of
lo! voltage (<;8 IV) and brief
duration (<;8 ms), over the
anterior and midtemporal regions
during non-+E6 sleep
0ic&et spi&es 'ursts of arciform !aves or single
spi&e-li&e !aves !ith a fre9uency
bet!een 7 and "" )3 and an
amplitude ranging from 78 to $88
IV,
observed over the temporal
regions bilaterally or
independently, during dro!siness
and light sleep, predominantly in
adults.
7/second spi&e and !aves
discharges (phantom spi&e
and !ave)
'ursts of 7 )3 spi&e and !ave
comple/es, usually
of lo! amplitude, lasting "=$ s.
)ughes = 0),6 and 2>E.
)ormal sleep EEG patterns

Stage *+ro,siness- = ,lpha dropout, gradually


replaced by $-<)3 lo! voltage activity.

Verte/ !aves = .ompounded potentials of $88ms


duration, !ith a positive spi&e follo!ed by a negative
!ave ma/imal at .3.

*>(5( - positive occipital sharp transients of sleep.


'isynchronous sharp !aves of ;8="88 IV, !hich may
sho! voltage asymmetriesF they appear over the occipital
regions, either isolated or in repetitive bursts.
)ormal sleep EEG patterns

Stage # *light sleep-

*rogressive slo!ing of
bac&ground activity, !ith fre9uencies ranging from 8.<; to
% )3, the occurrence of sleep spindles and L-comple/es.
)ormal sleep EEG patterns

Stage . *deep sleep-

*olymorphic slo! activities in the range of delta occupy


from $8 to ;8J of the recording

+hythmic activities in the fre9uency range bet!een ; and


# )?

(leep spindles !ith a fre9uency bet!een "8 and "$ )3


can still be foundF typical

L-comple/es can be elicited by arousing stimuli

,n Aalpha sleep pattern1 characterised by a <="" )3


activity prevalent over the anterior regions
)ormal sleep EEG patterns

Stage / *very deep sleep-

*olymorphic slo! activities in the range of delta


occupy more than ;8J of the recording .

(leep spindles are less fre9uently observed !ith


respect to the previous stage

RE$ sleep - repetitive bursts of hori3ontal rapid eye


movements, muscle atonia and EEG de
synchronisation characteri3ed by a faster(!ithin the
theta and beta ranges) and lo!er voltage activity
resembling that of light dro!siness replacing the slo!
!aves of stages C and %
Abnormal Patterns
A&normal Patterns

- E/clusion of artefacts.

-5he second step is the characteri3ation and


classification of the pattern and the description of the
distribution regarding general or focal, diffuse or
random appearance.

- 5he most important abnormalities are diffuse


slo!ing of bac&ground activity, continuous or
intermittent slo!ing !ith irregular theta or delta
activity and sharp paro/ysmal activity (epileptiform
patterns), !hich can also occur generalised or focally.

-iffuse slo!ing is also an indication of reduced


alertness, dro!siness or sleepiness, it is necessary to
monitor the sub:ects and record their clinical and
vigilance state.
The depression of normal EEG
rhythms

2actors favouring pathology

- is usually detected in more than one electrode.

- is not the only finding in an abnormal EEGs.

- difference bet!een depressed and non-depressed


EEG signals should be at least;8J of its amplitude

- 5he depression rarely occurs on its o!n, but often


in combination !ith other abnormalities.

- 5he presence of additional slo!ing adds to the


assessment of the underlying pathological condition.
The depression of normal EEG
rhythms

Increased amounts of fluid under the electrodes = I.


hematomas or hydromas. (lo! !aves in clinically
significant hydromas.

(>E and tumors

epression of spindles = iencephalon pathology.


EEG slo,ing and slo, ,aves

-efined as !aves slo!er than e/pected, particularly


!aves in theta fre9uency bands (%=</sec) or delta
fre9uency bands (<%/sec).

-2or the correct identification of slo!ing it is important to


perform EEG recordings during !a&ing states !ithout
dro!siness, because any change in vigilance and
sleepiness !ill automatically lead to an increased amount
of slo! !aves.
EEG slo,ing and slo, ,aves

+iffuse slo, ,aves - metabolic, to/ic or infectious


alterations of the entire brain.

0ocal slo,ing - frontal intermittent rhythmical delta


activity (2I+,) - is strongly suggestive of brain
occupying lesions (tumours, abscesses) and dysfunction
of deepsubcortical midline regions.

Temporal slo,ing - often seen in neural degeneration


(cortical dementia), ano/ic conditions or head in:uries.
EEG slo,ing and slo, ,aves

Parietal and occipital slo, activity - underlying


structural (space occupying) lesions should be
considered.

In combination !ith bi-temporal slo!ing, it can be


indicative of vertebral basilar malperfusion.
Epileptiform activity

5he identification of epileptiform potentials depends on


9uantification rather then 9ualification.

Sharp ,avesK these !ave forms are clearly Aoutside1


the regular bac&ground activity being suppressed or
interrupted by the occurrence of sharp !aves.

5he mean duration of sharp !aves ranges bet!een


<8 and $88 ms.
Epileptiform activity

Spi1es: spi&es usually have a duration of bet!een $8


and <8 ms.

5hey are often bi- or triphasic !ith an asymmetric


configuration, a steep increase and a shallo! decrease.

5he main component of spi&es is negative, the


bac&ground activity is interrupted.
Epileptiform potentials

5he most prominent epileptiform potential or !ave form is


the generalised C/sec spi&e !ave comple/, !hich is a
combination of spi&es and slo! !aves in a fre9uency of
C=% or ; )3 !ith a ma/imum over frontal regions.

,typical spi&e !ave comple/es have a fre9uency range


of C=7/sec and sho! irregular spi&es or poly spi&e
!aves.

(lo! spi&e !ave comple/es have a fre9uency belo! $.;


)3.
(harp paro/ysmal activity

(harp paro/ysmal activity is mar&ed by !ave forms in


interictal periods.

uring clinical sei3ures, there are different activity or


sei3ure patterns, usually consisting of focal or
generalised rhythmic activity.

5hese potentials must not be misinterpreted and a clear


distinction has to be made bet!een normal patterns
(such as verte/ sharp transience during dro!siness),
occipital lambda and central ne! rhythms that can
appear in sharp configurations.
Other periodic patterns

Triphasic ave!

Periodic sharp ave comple"es

Periodic temporal sharp aves

E"treme spindles

#itten pattern

$rontal arousal rhythms!


*eriodic lateralised epileptiform
discharges (*EE)

+egional, "/sec repetitive patterns often occur in acute


encephalopathies !ith a latency of "=$ days after lesion.

Include high-amplitude slo! !aves plus sharp !aves and


spi&es, sho! a !idespread unilateral (or bilateral)
distribution and are indicative of severe brain disorders.

)igh mortality
Abnormal clinical conditions and
associated EEG patterns!
EEG in Psychiatric disorders
EEG in Psychiatric disorders

5he rates of EEG abnormalities tend to be higher in


patient than non-patient populations especially in a
group of controversial !aveforms.

Electroencephalography in psychiatry is underused and


underestimated.

,ppro/imately 7%=7DJ of EEGs in psychiatric patients


can provide evidence of abnormal electrical activity
Psychosis

In patients in !hich psychotic symptoms possibly thought


to be due to epilepsy !ith single sei3ures or a series of
sei3ures (including non-convulsive status epilepticus),
EEG is usually the only diagnostic test allo!ing a reliable
diagnosis as a basis for ade9uate andimmediate
therapeutic conse9uences.

,n EEG !ould be one investigation modality to rule out


neurological causes for the hallucinations.
EEG in schi%ophrenia

&eviant patterns '

.hoppinessK lo! amplitude, disorganised fast activity,


!ith reduced or absent alpha and sometimes e/cess of
slo! activity.

(lo!ing of bac&ground activity.

)igh amplitude beta !aves.


(atatonia
iagnostic value if catatonia is secondary to

Epilepsy

Encephalopathy

-euroleptic malignant syndrome.


Panic &isorder

+esemblance to symptoms induced by temporolimbic


epileptic activity, particularly those originating fromthe
sylvian fissure.

(tudies comparing symptomatology of patients !ith panic


disorder agoraphobia (*,) and patients !ith .*(s
have reported much similarity, suggesting that there may
be a common neurophysiological substrate lin&ing .*(s
and *,.
Panic &isorder

Meffrey 0eilburg and his study on atypical panic attac&s.

(pecific EEG findings differ from study to study and


range from paro/ysmal epileptiform discharges to
asymmetrical increases in slo! !ave activity.

2ocal slo! !ave abnormalities are detected in as much


as $; percent of this population.

2ran& uffy !as able to use B-EEG to differentiate


bet!een panic patients and control sub:ects !ith
#$.;percent accuracy.
Obsessive)(ompulsive &isorder

0idespread increase of slo! !aves.

Epileptiform activities over the left temporal lobe also


!ere reported.

B-EEG studies involved the anterior regions of the scalp,


supporting the hypothesis of a frontal dysfunction in the
pathogenesis of >..

Eeslie *richep and her co-!or&ers demonstrated that B-


EEG could subtype sub:ects !ith >. as responders or
nonresponders to treatment !ith ((+Is.
6ood isorders

,bnormal EEG-findings can be detected in about


$8=%8J of patients suffering from mood disorder

4sing 9uantitative EEG analyses, several studies


have sho!n an increase in alpha- and/or theta-po!er
in patients !ith depression.

4nipolar or bipolar depression fre9uently sho!


alterations of vigilance regulation and abnormalities
of sleeping EEG-recordings !ith a shortened +E6
latency

Early EEG studies revealed a fre9uent increase of


small sharp spi&es ((((), 7/sec spi&e and !ave
comple/es and positive spi&es (especially in patients
!ith suicidal ideation).
A**ression and
impulse dyscontrol

It has also been sho!n that amongst groups of


prisoners convicted of murder, thehighest incidence
of EEG abnormalities (<%J) occurred in individuals
!hose crimes!ere apparently motiveless or had
minimal motives.

(ome studies report an increased hemispheric


asymmetry (usually delta activity) for frontotemporal
regions, and others report correlations bet!een
conventional EEG slo! !ave abnormalities, as !ell
as .5 scan abnormalities, and the degree of
violence.

5he presence of paro/ysmal EEG activity may


indicate that an anticonvulsant regime may help
decrease the fre9uency or severity of violent
episodes.
EEG and institutional a**ression

'arber et al. e/amined the clinical characteristics of ";


patients !ith repetitively assaultive behaviour.

>verall incidence of abnormalities not far different from


!hat has been reported in otherstudies (7;.7J), !hich
!as four times the incidence of EEG abnormalities in the
control group.

6ost fre9uently encountered abnormality !as diffuse


slo!ing of the bac&ground rhythm.
Treatment implications

0hether the appearance of an abnormal EEG predicts a


favourable therapeutic response to anticonvulsant
medications is currently un&no!n.

6onroe sho!ed that anticonvulsants can bloc&


electroencephalographic epileptiform discharges and can
lead to dramatic clinical improvement in individuals
e/hibiting repeated and fre9uent aggressive behaviour.
+orderline personality disorder

6ost common abnormality is diffuse EEG slo!ing. ,


neuropsychology testing !ould be recommended and
unless the cause of the slo!ing is correctable, this
patient is unli&ely to be suitable for dynamic
psychotherapy.

Epileptic discharges. 5he possibility of comple/ partial


sei3ures should be considered. , trial of antiepileptic
drugs should be considered if standard treatment is not
effective.