Psychiatric Aspects of Epilepsy
Section snippets
Epidemiology
Epilepsy has a prevalence estimated between 0.4% and 0.8%; a population-based study in Minnesota suggested a prevalence of 0.68% in 1980 [1]. In rural Ecuador, the prevalence of active epilepsy was measured as being between 0.67% and 0.80% [2]. Prevalence rises with age, probably because of the impact of cerebrovascular disease and head trauma on the development of new seizure disorders. Risk factors for the development of epilepsy in adults include a family history of epilepsy and a personal
Mood Disorders
Mood disorders are more common in patients who have epilepsy than in the general population. The lifetime prevalence of depression in the general population was estimated as 16.2% in the National Comorbidity Survey Replication [8], but in a different study the prevalence of depression was 32.6% in people who had been told they had epilepsy and 39.7% in people who had active epilepsy [9]. A United Kingdom–based population survey found a similar prevalence of depression (36.5%) in patients who
Anxiety Disorders
Anxiety disorders have received less attention than mood disorders in epilepsy. Patients report fear with seizures, and up to 15% report fear as part of the aura [35]. Patients who have frequent seizures actually report lower levels of anxiety about seizures than do patients who are better controlled, perhaps because of conditioning [36]. Anxiety impacts quality of life for epilepsy patients independent of depression or seizure frequency [7].
Psychotic Disorders
Psychosis and epilepsy have a long and intertwined history. After a period in the early twentieth century when it was thought that epilepsy and psychosis could not coexist [37], Slater and Beard [38] proposed that the disorders coexist more frequently than by chance. Since then, the prevalence of psychosis in epilepsy has been estimated to be as high as 9% [39]. Risk factors for psychosis in epilepsy seem to include bitemporal seizure focus and clustering of seizures [40], but studies differ on
Aggression
The relationship between aggression and epilepsy is complex and not well understood. In general, two types of aggression are seen in patients who have epilepsy. Some episodes of aggression are clearly linked to seizure activity and are best understood as peri-ictal phenomenon. Other aggressive acts seem to be unrelated to the timing of seizures and may be part of the patient's underlying character structure, caused by the socioeconomic circumstances that frequently arise in epilepsy or related
Personality in Epilepsy
Given the high level of psychosocial disability and the chronic, sometimes life-long, course associated with epilepsy, changes in personality among those who have epilepsy would seem almost inevitable. Physicians have been interested in questions about personality in epilepsy since at least the nineteenth century, and a number of changes have been reported in patients who have TLE (Box 2). Not all studies of patients who have TLE demonstrate personality changes, and other areas of the brain,
Attention and Impulsivity
Disorders of attention, including attention-deficit hyperactivity disorder (ADHD), have long been noted in both children and adults who have epilepsy. A review of the subject found an estimated prevalence of ADHD among children who had epilepsy of 14% [73]. Children who have comorbid epilepsy and ADHD have lower IQ scores than the general population and also function at a lower level than their IQ scores (when > 80) would predict [74]. Comorbid psychiatric disorders, including depression,
Antiepileptic Medications
The majority of patients who have epilepsy are treated with AEDs to control their seizures. These medications have psychotropic effects that must be considered when evaluating patients who have epilepsy. Many of the AEDs are used in psychiatry as mood stabilizers, but other effects of the medications are less well understood. The following is a review of the psychotropic effects of commonly used AEDs (Table 1) [80], [81], [82], [83].
Other Psychotropics in Epilepsy
Given the high rates of psychiatric disorders in epilepsy, many other psychotropics are used in epileptic patients. Many of these agents may interact with AEDs or change the seizure threshold (Table 2). Many of the newer psychotropics have proven to be relatively safe for use in epilepsy and have opened the door to safer treatment for epileptic patients. A brief review of psychotropics and their safety in epilepsy follows.
Patients who have epilepsy often require treatment with antidepressants.
Epilepsy Surgery
Surgery for intractable TLE has become more common as techniques have improved. Patients generally have a portion of the anterior temporal lobe removed; in one series, 58% of patients experienced a remission of seizures [117]. These patients also experienced a significant improvement in quality of life when compared with those who had medical management [117]. Patients often have high rates of psychiatric comorbidity before surgery and should undergo psychiatric evaluations before surgery;
Nonepileptic Seizures
Psychogenic nonepileptic seizures (PNES), sometimes referred to as “pseudoseizures,” are seizure-like behavioral events that occur in the absence of abnormal electrical discharge in the brain [126]. The reference standard of diagnosis is video-EEG monitoring [127]. Diagnosis of PNES can be complicated by comorbid epilepsy: 30% to 50% of patients who have PNES have epilepsy [128], and 20% to 60% of patients who have epilepsy have PNES [129]. A number of factors suggest PNES (Table 3).
The
Summary
Patients who have epilepsy face many challenges resulting from their illness and have frequent psychiatric comorbidities. Recognition of these disorders is increasing and is having a positive impact on patients' quality of life. Recent recommendations about a new classification system for psychiatric disorders related specifically to epilepsy and based on the relationship of symptoms to seizures, antiepileptic medications, and EEG changes should further research and treatment [141]. Especially
References (141)
- et al.
An incident case-referent study of epileptic seizures in adults
Epilepsy Res
(1990) - et al.
The role of comorbid psychiatric conditions in health status in epilepsy
Epilepsy Behav
(2007) - et al.
On the increased risk of developing late-onset epilepsy for patients with major affective disorder
J Affect Disord
(2003) - et al.
Risk factors for depression in patients with epilepsy
Epilepsy Behav
(2006) - et al.
Postpartum depression in women with epilepsy versus women without epilepsy
Epilepsy Behav
(2006) - et al.
The use of sertraline in patients with epilepsy: is it safe?
Epilepsy Behav
(2000) - et al.
Psychiatric comorbidity in epilepsy
Epilepsy Behav
(2005) - et al.
Rapid detection of major depression in epilepsy: a multicentre study
Lancet Neurol
(2006) Depression in epilepsy: prevalence, clinical semiology, pathogenic mechanisms, and treatment
Biol Psychiatry
(2003)- et al.
Influence of fatigue, depression, and demographic, socioeconomic, and clinical variable on quality of life of patients with epilepsy
Epilepsy Behav
(2007)