Mohapatra, et al.

: Psychiatric aspect of epilepsy

REVIEW ARTICLE

Psychiatric Aspects of Epilepsy : A review

Satyakam Mohapatra, Neelmadhav Rath
Mental Health Institute, S.C.B. Medical College, Cuttack , India

ABSTRACT

Comorbid psychiatric disorders are common in epilepsy patients. Patients with epilepsy are prone
to psychosis, depression, personality disorders, hyposexuality, and other behavioral disorders.
Comorbid psychiatric disorders are particularly common in temporal lobe epilepsy or complex
partial seizure. Though psychiatric comorbidity is common in epilepsy, it is under-recognized and
under-treated, both in adult and pediatric patients in specialty health care centers as well as in
community based health care centers. Early recognition and management of psychiatric disorders
in patients with epilepsy is extremely important, because it improves the quality of life and aids in
better seizure control.

INRODUCTION approximately equallydivided between those that

occur ictally or peri-ictally and those that occur
Epilepsy is one of the most common chronic
interictally . Manyauthors accept the proposition
neurological disorders. The prevalence of
that the link between neurobehavioral disorders
epilepsyvaries across studies, but generally ranges
and temporal lobeor complex partial epilepsy is
from 4 to 10 per 1000 population. [1-5] Prevalencerate
particularly strong. Though psychiatric comorbidity
of epilepsy in India at 5.59 per 1,000 populations6.
is common inepilepsy, it is under-recognized
Epilepsy affects emotional, behavioral, social, and
and under-treated, both in adult and paediatric
cognitive functioning. Psychiatric and cognitive
patients inspecialty health care centers as well as in
disturbances are relatively commonin epilepsy,
community based health care centers.
especially in refractory epilepsy[7-9]. Indeed, there
is now general agreement that theincidence of
neurobehavioral disorders is higher in patients with
EPIDEMIOLOGY OF
epilepsy than in the generalpopulation. Epilepsy
PSYCHIATRIC DISORDERS IN
patients are prone to psychosis, depression,
EPILEPSY PATIENTS
personality disorders, hyposex-uality, and Vuilleumier and Jallon10 estimated that 20-30% of
other behavioral disorders. These problems are patients with epilepsy have differentpsychiatric
disorders. Epidemiological studies from
communities, psychiatric hospitals, andepilepsy
Corresponding Author clinics report a 20 to 60 percent prevalence of
Dr. Satyakam Mohapatra psychiatric problems among epilepsypatients
Mental Health Institute S.C.B. Medical College, 11. Among patients attending epilepsy clinics,
Cuttack approximately 30 percent had a priorpsychiatric
E mail - [email protected], hospitalization, and 18 percent were on at least one
psychotropic drug11. In recentpopulation based
surveys12, the 12 month prevalence of mental health

40 Volume 17, Issue 2 Eastern Journal of Psychiatry | July – December 2014

 Mohapatra, et al. : Psychiatric aspect of epilepsy

disorder was 23.5% andthe lifetime prevalence was PERI-ICTAL FEATURES

35.5%. A recent review reported the prevalence
Psychiatric disturbances can occur before seizures
of variouspsychiatric disorders in persons with
(prodromal), after seizures (postictal) . Somepatients
epilepsy are 30% for depression, 10–25% for
experience prodromal symptoms such as irritability,
anxietydisorders, 2–7% for psychoses and 1–2% for
depression, headache, confusion. Postictal psychosis
personality disor- ders13. Depression is thecommonest
consists of brief psychotic episodes that follow clusters
psychiatric condition reported in people with
of generalized tonic-clonicseizures. These psychotic
epilepsy[13-16]. Studies from India17 showed
episodes occur in patients who have complex
prevalence of psychiatric co-morbidity in people
partial seizures,frequent secondary generalization
with epilepsy is 28.7% Psychiatric disturbances,
to tonic-clonicseizures . The postictal psychosis of
primarily psychosis and personality disorders, are
epilepsyemerges after a lucid interval of 2 to 72 hours
two to three timesmore common in patients with
(with a mean of 1 day), during which theimmediate
complex partial seizures, most of whom have a
postictal confusion resolves, and the patient
temporal focus, compared to those with generalized
appears to return to normal. The postictalpsychotic
tonic-clonic seizures.
episodes last 16 to 432 hours (with a mean of 3.5
days) and often include grandiose orreligious
PSYCHIATRIC delusions, elevated moods or sudden mood swings,
MANIFESTATIONS OF EPILEPSY agitation, paranoia, and impulsivebehaviors, but
In epilepsy, psychiatric behaviors can be no perceptual delusions or voices are heard. The
conceptualized in relation to the ictus or postictal psychoses remitspontaneously or with the
seizuredischarges. These behaviors occur as part use of low-dose psychotropic medication.
of the ictus, peri-ictally, or during the interictal
period. INTERICTAL FEATURES

ICTAL FEATURES SCHIZOPHRENIFORM PSYCHOSIS

Seizure discharges can produce psychic auras such as Epilepsy patients with a schizophreniform
mood changes, derealization anddepersonalization, psychosis have a chronic interictal illness without
olfactory and gustatory hallucinations, visual or aknown direct relationship to seizure events or ictal
auditory hallucinations (ofteninvolving poorly discharges. Torta and Keller18 reported thatthe
defined shapes or sounds, although there may risk of this psychosis in populations of patients
be complex visual scenes orspeech), ictal fear, with epilepsy may be 6-12 times that of thegeneral
ictal depression and pleasurable auras (“ecstatic population, with a prevalence of about 7-8% (in
auras”). Another psychicaura is “forced thinking,” patients with treatment-refractorytemporal lobe
characterized by recurrent intrusive thoughts, epilepsy, the prevalence has been reported to range
ideas, or crowding ofthoughts. Forced thinking from 0-16%). Many patientsdevelop worsening
must be distinguished from obsessional thoughts psychotic symptoms that are concomitant with an
and compulsiveurges. Epileptic patients with forced increase in seizurefrequency or with antiepileptic
thinking experience their thoughts as stereotypical, drug withdrawal, and a few others have worsening
out-ofcontext,brief, and irrational, but not necessarily psychoticsymptoms on control of the seizures
as ego dystonic. (alternating psychosis). The terms alternating
psychosis andforced or paradoxical normalization
refer to this demonstrable antagonism between
the psychosisand the seizures or EEG discharges.
In epilepsy patients interictal psychosis often

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 Mohapatra, et al. : Psychiatric aspect of epilepsy

have an earlyage of onset of seizures and long occasionally follows complexpartial seizures, even
interval of poorly controlled partial complex when ictal experiences do not include depression.
seizures, usuallywith secondary generalized tonic-
clonic seizures, left temporal focus, mediobasal PERSONALITY DISORDERS
temporallesions, recently diminished seizure
Prevalence rate of personality disorders among
frequency. This interictal psychosis may evolve from
epileptic patients is approximately 18% 22. which
priorrecurrent postictal psychotic episodes. There is
including borderline, histrionic, and dependent
atypical paranoid psychosis with sudden onset, more
disorders. The most common personalitydisorder
hallucinations than schizophrenia, less systematized
in epilepsy is a borderline personality. Personality
delusions than schizophrenia, relativepreserved
profiles of patients with epilepsy canbe explained
affect, few schneidreian first-rank symptoms, more
by a complex combination of the effects of
religiosity than schizophrenia, failure of personality
(1) dealing with a chronic illness (beingepileptic),
deterioration, less social withdrawal.
(2) antiepileptic drugs, and (3) temporal lobe
pathology. Although there is no generalepileptic
DEPRESSION personality, a group of traits termed the Gastaut-
Depression is the most frequent psychiatric Geschwind syndrome occurs in asubset of patients
co-morbidity in epilepsy but very often with complex partial seizures. These patients are
remainsunrecognized and untreated. Depression serious, humorless, andoverinclusive and have
among patients with epilepsy range from 20 to 55% an intense interest in philosophical, moral, or
inpatients with recurrent seizures and 3 to 9% in religious issues. Theydemonstrate viscosity, the
patients with controlled epilepsy19. Mostcommon tendency to talk repetitively and circumstantially
mood symptom is chronic interictal depression or about a restrictedrange of topics. They can spend
dysthymia. Some investigators referto this condition a long time getting to the point, give detailed
as the “interictaldysphoric disorder of epilepsy”. backgroundinformation with multiple quotations,
Blumer20 suggested thatalmost one third to one half or write copiously about their thoughts and
of all patients with epilepsy seeking medical care feelings (hypergraphia). Although these personality
suffer from thisform of depression severely enough characteristics do occur in some epileptic
to warrant pharmacological treatment. Patients patients,they may not be specific for patients with
experien- cingdepression in epilepsy often do not seizure disorders.
meet the criteria of major depressive disorder (i.e.,
theirsymptoms are less severe) but they also typically ANXIETY IN EPILEPSY
exhibit a more intermittent course than dopatients
Anxiety in epileptic patients may occur as an ictal
with dysthymic disorder21. They exhibit mixed
phenomenon, as normal interictal emotion oras part
depressive-somatoform and affectivesymptoms.
of an accompanying anxiety disorder, as part of an
This group of patients show a good therapeutic
accompanying depressive disorder, orin association
response to antidepressantmedications.
with nonepileptic seizure like events as part of an
The rare occurrence of ictal depression may not only underlying primary anxietydisorder. Anxiety and
outlast the actual ictus but also may lead tosuicide. panic disorders occur among epileptic patients and
Depression also occursperi-ictally. Episodic mood must be distinguishedfrom simple partial seizures
disturbances, often with agitation, suicidal behavior, manifesting as anxiety or panic. Anxiety is higher in
and psychotic symptoms, may occur with increasing focal (morefrequent in temporal lobe) epilepsy than
seizure activity. Finally, postictal depression in generalized epilepsy.
is common, and a prolonged depressive state

42 Volume 17, Issue 2 Eastern Journal of Psychiatry | July – December 2014

 Mohapatra, et al. : Psychiatric aspect of epilepsy

SUICIDE sexualarousal and a lower sexual drive. Men have

an increased risk of erectile dysfunction, suggestinga
The risk of completed suicide in epilepsy patients
neurophysiological component, and studies of sex
is four to five times greater than that amongthe
hormones suggest the possibility of asubclinical
nonepileptic population, and those with complex
hypogonadotropichypogonadism.
partial seizures of temporal lobe origin havea
particularly high risk, as much as 25 times greater.
Death by suicide occurs in 3 to 7 percentof
PSYCHOTROPIC EFFECTS OF
epilepsy patients. Most suicidal behavior among
ANTIEPILEPTIC DRUGS
epileptic patients is not directly due toreactions There is a risk of depression related to barbiturates
to the psychosocial stressors of having a seizure and topiramate, and possibly to phenytoin.
disorder. Rather, these patients arelikely to attempt Underlying depression and anxiety symptoms may
suicide in conjunction with borderline personality be exacerbated by levetiracetam, whilepsychotic
behaviors and are likely tocomplete suicide during symptoms, albeit rare, have been reported with
postictal psychosis. Contributors to successful topiramate, levetiracetam, andzonisamide23.
suicides include paranoidhallucinations, agitated
compunction to kill themselves, and occasional ictal SEIZURE THRESHOLD
commandhallucinations to commit suicide. LOWERING EFFECT OF PSYCHO-
TROPIC MEDICATIONS
AGGRESSION IN EPILEPSY Seizure threshold lowering effect of psychotropic
Aggression can occur in relation to an ictus, medications is usually not a problem but
as exemplified by this patient's subacute canoccasionally reach clinical significance in poorly
postictalaggression. Most aggression among epilepsy controlled epilepsy. Psychotropic drugs aremost
patients is not related to epileptiform activity. convulsive with rapid introduction of the drug
Aggression in epilepsy is usually associated with and in high doses. Clozapine , for example,has
psychosis or with intermittent explosivedisorder and induced seizures in 1.0 to 4.4 percent of patients,
correlates with subnormal intelligence, childhood particularly when the dose was rapidlyincreased.
behavior problems, prior headinjuries. When initiating psychotropic therapy, it is best to
start low and go slow whilemonitoring antiepileptic
HYPOSEXUALITY levels and EEGs.(Table 1)

Patients with epilepsy tend to be hyposexual.

Men and women experience disturbances of

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 Mohapatra, et al. : Psychiatric aspect of epilepsy

Table 1 : Showing seizure threshold lowering effect of psycho-tropic medication

Potential Antipsychotics Antidepressants Other Psychotropics

High Clozapine Bupropion
Imipramine
Maprotiline
Amitriptyline
Amoxapine
Nortriptyline

Moderate Most piperazines Protriptyline Lithium

Thiothixene Clomipramine

Low Fluphenazine Doxepin

Haloperidol Desipramine
Loxapine Trazodone
Pimozide Trimipramine
Thioridazine SSRIS
Risperidone
Olanzapine
Ziprasidone
Aripiprazole

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