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Tinjauan Pustaka
The Psychiatric Perspectives
of Epilepsy
Harsono
Department of Neurology, Faculty of Medicine Gadjah Mada University/
Dr. Sardjito Hospital Yogyakarta, Indonesia
Abstract: There are four perspectives of psychiatry in every patient with epilepsy. Those are
diseases, dimensions, behaviors, and life-stories. The disease perspective assumes that the cause
of a psychiatric symptom is a “broken part”; that is, biological dysfunction involving the nervous system. The dimension perspective is based on the recognition that human traits vary from
individual to individual along a continuum. Behavioral presentations in epilepsy can be caused
by the epilepsy itself (pre and peri-ictal: prodromal/aura/automatisms, postictal especially
frontal disinhibition, focal discharges), anti-epileptic drugs, underlying brain dysfunction, personal/parental reaction or response to having epilepsy, and idiopathic. Individuals also experience problems because of what they encounter in life and the meanings they attribute to these life
events. These meaningful connections form the basis of the life-story perspective.
Key words: psychiatry, epilepsy, behavioral presentation, anti-epileptic drugs, brain dysfunction
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123
The Psychiatric Perspectives of Epilepsy
Berbagai Perspektif Psikiatrik pada Epilepsi
Harsono
Bagian Ilmu Penyakit Saraf, Fakultas Kedokteran Universitas Gadjah Mada /
SMF Penyakit Saraf RS. Dr. Sardjito Yogyakarta Indonesia
Abstrak: Ada empat perspektif psikiatrik di setiap pasien epilepsi, yaitu penyakit, dimensi, perilaku
dan riwayat hidup. Perspektif penyakit mengandung pengertian bahwa penyebab munculnya
gejala psikiatrik merupakan bagian terpisah, yaitu disfungsi biologik di sistem saraf. Perspektif
dimensi berdasarkan pemahaman bahwa human traits bervariasi, dari individu satu ke individu
lain yang merupakan suatu kontinum. Terjadinya perubahan perilaku pada epilepsi dapat
disebabkan oleh epilepsinya itu sendiri (pre- dan peri-ictal yang meliputi prodroma /aura /
automatisme, postictal khususnya disinhibisi frontal, bangkitan fokal), maupun oleh faktor lain
misalnya obat anti-epilepsi, penyakit otak yang mendasarinya, reaksi atau tanggapan personal/
orang tua terhadap epilepsi, dan idiopatik. Sementara itu, pasien epilepsi juga mempunyai
pengalaman yang khas dalam menjalani kehidupannya yang merupakan basis terbentuknya
perspektif pengalaman hidup.
Kata kunci: psikiatri, epilepsi, obat anti-epilepsi, disfungsi otak
Introduction
All illness has both psychological and physical dimensions. This may seem a startling claim, but on reflection it is
uncontroversial. Diseases donot come to doctors, patients
do–and the processes by which patients detect, describe,
and ponder their symptoms are all eminently psychological.
This theoretical point has practical implications. If we adopt
a “bio-psycho-social” approach to illness generally, one
which recognizes the biological, psychological, and social
aspects of our lives, we become less likely to neglect the
treatable psychological origins of many physical complaints
(from globus hystericus to full blown conversion disorder)
and the treatable psychological consequences (such as depression and anxiety) of much physical disease.1
Psychiatric conditions occur frequently in epilepsy and
their manifestations are diverse. Evaluation and management
require knowledge of disease processes relevant to epilepsy
and psychiatry, as well as the role of other factors that affect
the expression of psychiatric illnesses such as behaviors,
temperament, cognition, and life events.2
People who have epilepsy seem particularly liable to
certain major psychiatric disorder i.e., a chronic interictal
psychoses that closely resembles schizophrenia; and episodic psychotic states, some of which many arise in close
temporal relation with seizure activity. These disorders are
conventionally referred to as the psychoses of epilepsy although some of the episodic forms would be more accu-
124
rately described as acute confusional states. These conditions have for long puzzled and intrigued psychiatrists and
neurologist, but in recent years this interest has quickened
especially among biologically minded psychiatrists in search
of a neurological model for schizophrenia.3
In the postwar year of the 20th century, the division between neurology and psychiatry seemed nearly complete.
Such a separation between the “organic” biologically based
disorders with florid neurological physical signs, and the
“functional” mentally ill behaviorally, affectively or psychotically disturbed with minimal physical neurological abnormalities on examination would have seem extraordinary a
couple of centuries earlier. For pediatric neurologists it has
been the rare psychiatrist who has been a regular participant
in their meetings and whose writings have proved educational and inspirational. Similarly, it is rare for neurologists to
be involved in teaching child psychiatrists and few have had
training in the psychosocial aspects of patient management.
It is to be hoped that pediatric neurology and child and adolescent psychiatry will come even closer with a new generation of neuropsychiatrists.4
There are four perspectives or lenses concerning the
psychiatric issues in epilepsy; those are diseases, dimensions, behaviors and life stories.2 The purpose of the following discussion on such perspectives is to provide a framework for evaluating patient symptoms and related phenomenology (description), determining causes of psychiatric dis-
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The Psychiatric Perspectives of Epilepsy
turbance (explanation), and formulating treatment programs.
Diseases Perspective
The diseases perspective assumes that the cause of
psychiatric symptom is a “broken part” that is, biological
dysfunction involving the nervous system. In this context,
the brain is also substrate for psychiatric syndromes and
related disease processes appear to contribute both to epilepsy and to psychiatric conditions. Examples are major depression and panic disorder, which are more prevalent in
epileptic patients than in the general population.2,5
Schizophrenia
Over the past four decades a consensus has begun to
take shape - namely, that certain forms of epilepsy may act
as risk factors for the subsequent development of a chronic
interictal psychosis, a syndrome sometimes referred to as
the schizophrenia-like psychoses of epilepsy (SLPE). This
psychosis does resemble schizophrenia in its phenomenological manifestations, pursues a similar course, is a responsive to antipsychotic medication, and is largely uninfluenced
by concurrent seizure activity. Epilepsy and psychosis may
each arise out of some form of cerebral dysfunction common
to both; or psychosis may be a consequence of seizure activity. The first seems more likely. Most forms of epileptic
psychosis occur more commonly in the partial epilepsies,
especially complex partial seizures. Within the surgical series patients with developmental lesions may be at particular
risk.3
Depression
Depression in epilepsy may be linked temporally to seizures, but the most common disorder is that of interictal
depression. In addition to the recognized symptoms of anhedonia (lack of enjoyment), reduced appetite, poor energy,
and sleep disturbance, interictal depression or dysphoria is
more likely to be associated with agitation and psychotic
features or impulsive self harm than is depression in people
without epilepsy; a fact worth remembering when faced with
a restless or truculent patient in the clinic. Pre-ictal depression may appear hours before a seizure; if this pattern can be
recognized a short acting benzodiazepine such as clobazam
may be used to abort seizures. Ictal depression is rare, much
less common than ictal fear or anxiety, but can be profound.6
Multiple epidemiological studies have shown that depression is the most frequent comorbid psychiatric disorder
in patients with epilepsy. Prevalence rates range from 20%
to 55% in patients with recurrent seizures and 6% to 8% in
patients with well-controlled seizures. In addition, suicide is
one of the most common causes of death in patients with
epilepsy; it was found to be almost 10 times more frequent in
these patients than in general population.7 In a study carried
out in a groups of patients with refractory epilepsy admitted
to a video-EEG monitoring unit, 50% of the patients were
Maj Kedokt Indon, Volum: 58, Nomor: 4, April 2008
depressed, 19% had suicidal ideation, and only 17% were
being treated with antidepressant medications. Despite the
high prevalence of depression and suicide risk, depression
often goes unrecognized and untreated in this patients.8
Many investigators have tried to find an association
between depression and epilepsy with respect to age of onset and seizure type, frequency, and duration. Depression
has been identified more frequently in patients with seizures
involving limbic structures (predominantly temporal and frontal lobes) and less often in patients with generalized seizure
disorders. Laterality of seizure focus also has been considered as a possible risk factor, with seizure disorders of left
hemispheric origin being more likely to be associated with
depression. This association has been questioned by several investigators, however. There is evidence that seizures
originating in or propagating to the frontal lobes increase
risk of depression. For instance, patients with left temporal
focus and depression have been found to display bilateral
inferior frontal hypometabolism on both positron emission
tomography (PET) and single proton emission computed
tomography (SPECT) studies. In fact, decreased frontal metabolism on PET and SPECT has been found in primary depression.8,9
Epilepsy and depression may share common pathogenic
mechanisms mediated by abnormal serotonergic, noradrenergic, GABA-ergic and dopaminergic secretion in the central
nervous system. In primary depression, decreased activity
of these neurotransmitters has been identified as one of the
pivotal pathogenic mechanisms and the basis for antidepressant pharmacologic treatment.8
The location of the seizure focus is also relevant to the
development of affective illnesses. Some studies report a
higher prevalence of mood disorders in temporal lobe epilepsy (TLE) than in other epilepsy types, supporting a specific role for temporal-limbic dysfunction in mood regulation.
This finding has not been consistent, however. Hemispheric
location of the seizure focus has also been an area of interest, especially in TLE. Several studies associate left-sided
foci with an increased risk of depression and right-sided foci
with an increased risk of mania. These findings parallel laterally findings for mood disorders after cerebrovascular events,
tumors, and head injury.2
The etiology of depression in epilepsy is multifactorial,
encompassing both neurobiologic and psychosocial risk factors. Among the potential neurobiologic determinants, special interest has focused on epilepsy variables, such as age
at epilepsy onset, type of seizures, their frequency and severity, presence of status epilepticus, medication, and the
laterality of temporal lobe spike focus. Among patients with
chronic temporal lobe epilepsy, adequacy of neuropsychological functioning seems to be adversely affected by
comorbid interictal depression. Although there is no greater
incidence of depression in left compared with right temporal
lobe epilepsy, the hypothesis is raised that neuropsycho125
The Psychiatric Perspectives of Epilepsy
logical performance may be more adversely affected in patients with left temporal lobe epilepsy.10, 11The psychosocial
factors include mainly social stigma, adverse life events, fear,
poor self esteem, lack of mastery, low rate of marriage and
high unemployment, and a history of personal and family
depressive illness.10
Panic Disorder
The lifetime prevalence of panic attacks in patients with
epilepsy is 21%, as compared with the 1% prevalence rate in
the general population. Although this increased rate of panic
attacks in epilepsy implicates underlying diseases processes
involving the limbic system, the disease perspective is also
salient because interictal panic disorder represents a paroxysmal condition that can be misdiagnose as an epileptic seizure. Conversely, anxiety symptoms and features of panic
attacks can occur during seizures, and they need to be distinguished from interictal anxiety symptoms. Accordingly,
failure to distinguish panic attacks from seizure can lead to
inappropriate treatment with either anti-panic medications
or higher doses of anti-epileptic medications.12-14
Anxiety
As with depression, anxiety can be seizure related or
interictal. Fear is a common manifestation of partial seizures
originating in the temporal lobe and it can sometimes be
difficult to distinguish between these and panic attacks. Panic
disorder consists not only of discrete panic attacks but also
an anticipatory fear of them and their consequences which
in itself can be disabling; this, together with the short duration and lack of situational triggers in seizures, usually provides the diagnosis, but occasionally panic attacks can coexist with epilepsy. The symptoms of generalized anxiety
disorder are excessive worry and anxiety in association with
the somatic symptoms of restlessness, poor concentration,
sleep disturbance, fatigue, irritability, and muscle tension.
As with depression, asking open ended questions about a
patient’s wellbeing may elicit these symptoms or they can
be sought more actively by the use of screening questionnaires. Phobic disorders are common in epilepsy and are
often the result of poor seizure control leading to agoraphobia and social phobia. Anxiety is often a dominant symptom
of the adjustment disorder which most patients go through
when first diagnosed with epilepsy.6
Dimensions Perspective
Temperament or personality and intelligence are viewed
as dimensional in the sense that these characteristics in
individuals are distributed along a continuum. In any individual, these characteristics are composed of assets and
liabilities that, in their interactions with life circumstances,
yield normal as well as abnormal emotional and behavioral
responses. Where a person falls on the continuum of given
temperamental or intellectual trait influences vulnerability to
126
psychiatric disturbances under stressful circumstances. Thus,
a person’s vulnerabilities are merely potential until exposed
by some provocation. In patients with epilepsy, inherent central nervous system (CNS) pathology and the direct effects
of anti-epileptic medications and seizures or postictal states
affect intellectual and, potentially, temperamental attributes.
However, the psychological experience of recurrent seizures
can also be a significant stressor that brings out vulnerabilities.2
Temperament
The notion of an “epileptic personality” has prevailed
for many years, even though most patients with epilepsy are
no more vulnerable to emotional problems due to their temperament than members of the general population. Some argue that descriptions of unique personality features among
epilepsy patients were based on actual seizure phenomena
or the effects of cognitive impairment, institutionalization,
social stigma, intensified observation, medication side effects, and unrecognized comorbid psychiatric illnesses. The
exception may in some patients with seizures of temporal
lobe origin whose personalities are classically described as
“viscous” or “sticky”, in reference to a ponderous, overly
detailed, and circumstantial mode of communication that listeners tend to find tedious. This same style is evident in
extensive written communication, referred to as hypergraphia.
Decreased sexual interest (and, on rare occasions, increased
sexual interest or fetishism) and religiosity are also observed
in some patients with TLE.1,15
Intelligence
The other important psychiatric dimension, intelligence,
has special significance in the treatment of patients with epilepsy. Cognitive deficits in epilepsy related to brain damage
reflect a “broken part” and should be viewed as the impact of
a disease process on a psychiatric dimension.2
Cognitive deficits are common in people with epilepsy,
but it is difficult to identify the causes in any individual because many interrelated factors may be involved. These include a) the occurrence of seizures of various types, b) the
pathophysiology underlying epilepsy, c) possible cerebral
pathology, either causative or secondary to the epilepsy, d)
anti-epileptic drugs (AEDs), e) social stigma and educational
deprivation, f) genetic factors, g) disruption of sleep by seizures and by discharges, and h) subclinical discharges causing transitory cognitive impairment (TCI). It is often unclear
which of these interrelated factors contribute to the cognitive problems of an individual. By contrast, the presence of
TCI in a given patient can be reliably determined. The individual is his own control: function during discharges can be
compared with that when they are absent.16
Epilepsy is the most common serious neurological disorder affecting people with intellectual disabilities (mental
retardation) with prevalence ranging from 20-40%, 30 times
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The Psychiatric Perspectives of Epilepsy
higher than the general population rate. Three-quarter of the
latter become seizure free on anti-epileptic drug therapy. Epilepsy in people with intellectual disabilities is more difficult
to manage, although clinical guidelines have recently been
developed by a working group of the International Association for the scientific Study of Intellectual Disability.17
All established AEDs have been reported to be associated with absolute cognitive side effects (i.e., all the investigated drugs have effects when compared with no treatment).
These effects are definitely large for phenobarbital and possibly larger for phenytoin than for carbamazepine or valproic
acid. But even these last two drugs, generally considered to
be drugs with a safe cognitive profile, have cognitive effects, mostly resulting in a mild general psychomotor slowing. The respective differences between the four investigated AEDs can be considered as small, with the exception
of the cognitive effects of phenobarbital, which has positively a less favorable cognitive profile when compared with
phenytoin, valproic acid, and carbamazepine.18
Behavioral Perspective
Behaviors are actions defined by their consequences:
they are goal-directed. For example, with the behavior of
eating, the goal is ingestion of food. The details of how the
food is obtained, prepared, and brought to the mouth vary
widely from person to person. In the end, however, the consummatory act is fairly stereotyped. Some behaviors,
such as eating, sex, and addictive drug use, are further motivated by underlying drive states that pose special challenges
during treatment. There are also “non-motivated” behaviors, such as self-injury and abnormal illness behavior (hysteria). The behavioral perspective is concerned with the
motivated and non-motivated behaviors that are maladaptive, such aggression, substance abuse, paraphilias, selfinjury, eating disorder, and illness-related behavior.2,19
Behavioral disorders that have been consistently seen
in children with epilepsy are hyperactivity, attention disorders, social withdrawal, conduct problems, and aggression.
Biological, psychosocial, demographic, and medication factors contribute to behavior disorders.19 Behavioral problems
need to be considered separately form psychiatric disorder
because general factors, more closely associated with disability, are stronger predictors of their occurrence.15,19
Epilepsy in children is often accompanied by behavioral disorders. In an epidemiological study, behavioral disorders are found 4.7 times higher prevalence in children with
epilepsy compared with healthy children. The prevalence is
also higher than in children with other chronic illnesses such
as cardiac disease or diabetes.20,21
Surgery in children with pharmacoresistant focal epilepsies is not only followed by successful seizure control,
but is also accompanied by an early improvement of behavioral disorders. These behavioral improvements are assumed
Maj Kedokt Indon, Volum: 58, Nomor: 4, April 2008
to result directly from the removal of epileptic focus. They
are not predictable on the basis of preoperatively available
information and the site of surgery, but depend on the seizure outcome.20
Aggression
Aggression is a behavioral problem that is frequently
attributed (rightly or wrongly) to epilepsy. Earlier in the 20th
century, criminality was associated with epilepsy, an assumption that was probably related more to existing theories of
criminality. Although it was known that not all epileptics were
criminals, the diagnosis of epilepsy was considered in many
criminals, even in the absence of a history of seizures.2
Abnormal Illness Behavior
The primary goal of abnormal illness behavior is to assume the sick role inappropriately in order to address some
conflict or achieve some secondary gain, for example, attention or reduced expectations. Pseudoseizures, usually regarded as a form of conversion disorder, are a type of abnormal illness behavior that involves mimicking the behaviors
of an ictal event. They tend to, but do not always, lack the
usual features of epileptic seizures, such as a brief duration
(30 to 90 seconds), tongue-biting or other injuries, incontinence, or postictal confusion.22
Life-Story Perspective
Life-story perspective focuses not on what the patients
have (disease perspective), nor on what the patients are (dimension perspective), nor on what they do (behavior perspective), but on what they encounter. The application of
life-story perspective involves getting to know the patient
as an individual. Sometimes the events that patients encounter in their lives lead to demoralization, a state of helplessness, hopelessness, confusion, and subjective incompetence.23
Many burdens and obstacles confront the patient with
epilepsy. Stigma associated with epilepsy and the seizures
themselves can interfere with social contacts. Classmates
can become frightened if they witness a seizure at school.
Unpredictable loss of control over bodily functions can be
embarrassing, and adolescents may find it difficult to develop friendships; for example, patients may fear having a
seizure while on a date. The prohibition on driving and other
burdens during this stage of life (adolescence) become obvious. Such disruptions in social development can continue
throughout life, with difficulties achieving intimate relationships and problems with employment. Patients miss work
because of seizures, postictal symptoms, and doctor appointments. Even without prejudice in the workplace, certain careers may not be available, (e.g., airline pilot) particularly
those in which seizures create a dangerous risk to the patient
or others.2
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The Psychiatric Perspectives of Epilepsy
Treatment
The patients’ perceptions of their ability to change their
own seizure behavior may be an important factor and this
has not been investigated with a view to predicting success
or failure of psychological treatments for epilepsy. Psychological approaches, by contrast with pharmacological and
neurosurgical techniques, place particular ones on the patient to bring about change that will result in seizure reduction, rather than simply relying on external agents (drugs) or
techniques (neurosurgery). It may be, for example, unwise to
investigate a patient’s suitability for neurosurgical treatment
of their seizures and to explore psychological interventions
at the same time. Psychological interventions imply that seizures can be brought under control by change on the part of
the patient. The possible use of neurosurgical interventions
implies the patients would not otherwise achieve control of
their seizures. Simultaneous psychological and physical investigations may reduce the motivation of the patient to
make sufficient effort for psychological treatment to have a
maximum of success.24
Among patients with chronic temporal lobe epilepsy,
adequacy of neuropsychological functioning seems to be
adversely affected by comorbid interictal depression. Although there is no greater incidence of depression in left
compared with right temporal lobe epilepsy, the hypothesis
is raised that neuropsychological performance may be more
adversely affected in patients with left temporal lobe epilepsy. Depression in epilepsy seems to be underrecognized,
or at least undertreated, and greater attention should be directed to early recognition and treatment of depression given
its adverse effects on quality of life.11
Many of the principles guiding psychiatric treatment in
patients with epilepsy are similar to those used for patients
without epilepsy. A comprehensive treatment plan can be
devised that involves all four perspectives. Treatment will
probably include use of an antidepressant medication and
possibly an antipsychotic medication if psychotic symptoms
are present interictally. This use of medication is based on
the disease perspective, and an extensive review of the pharmacologic treatment of psychiatric comorbidity in epilepsy
is available. The potential role for anti-epileptic medications
in the treatment, causes of psychopathology and drug-drug
interactions also needs to be addressed. Complicated medication regimens are best avoided in patients who have intelligence or temperamental vulnerabilities that increase the risk
of poor adherence.2
Summary
There are complex interactions between psychiatric
phenomena and epilepsy. Psychiatric phenomena can be
associated with the seizure itself, as well as the peri-ictal and
interictal phases of epilepsy. Patients with epilepsy may be
contending with the stigma associated with the diagnosis.
Accepting the additional diagnosis of psychiatric disorder
128
may compound the stigma. Assessment of psychopathology in epilepsy requires knowledge of the patient’s specific
epilepsy syndrome and whether there are special vulnerabilities to psychiatric dysfunction related to that particular
epilepsy syndrome. Treatment should be based on a comprehensive evaluation with regard to the effectiveness and
avoidance of the adverse effects of medications.
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