Neuropsychiatric Aspects of Epilepsy

Psychosis

Ictal Psychoses - include non-convulsive status:

  • Prolonged automatisms
  • Confusion
  • Episodic hallucinations  
  • Mood changes
  • Paroxysmal EEG changes
  • Clearly episodic, rarely >1 hour

Post-ictal Psychoses- Fugues:

  • Wandering
  • Altered behaviour
  • Amnesia
  • ?“dissociative”
  •  EEG usually “normal”

Twilight states:

  • Abnormal subjective experience (cognitive and affective)
  • Perseveration
  • Subtle cognitive impairments
  • Paranoid hallucinatory experiences
  • May be associated with deep EEG changes or with “forced normalization”

Chronic Inter-ictal Psychoses: 

  • 3% risk - especially if left temporal lobe

Chronic paranoid hallucinatory:

  • “Schizophreniform”
  • Onset 10-15 years after epilepsy
  •  Less Family history
  •  Pre-morbid personality
  •  Warmer affect
  •  Less personality deterioration

Affective disorder and Epilepsy

Ictal emotion:  

  • Fear, also depression,                            
  • Rarely elation                          
  • Can be prodromal, partial status, post ictal                      
  • Lack precipitant                                                                        
  • Sudden onset and ending                           
  • Have a primitive, unvarying quality

Inter-ictal depression and anxiety:

  • 15-45% prevalence
  •  Major Affective Disorder 11% (cf 4.9% gen pop)
  •  62% lifetime prevalence (cf 17% gen pop)
  •  High anxiety and hostility scores
  •  Risk after surgery: 2yrs=10%(successful or not)
  •  Multi-factorial causation (biological,  personal, family and societal factors)
  •  Treatment: attend to these factors:
    SSRIs, can use ECT
    A range of interactions, mostly “academic”

Personality and Epilepsy

A long and misleading history of prejudice

  • Possibly a "Temporal lobe personality syndrome”
  • Bear and Fedio 1977 :
    • Humourless sobriety
    • Circumstantiality
    • Viscosity
    • Religiosity
    • Emotionality (Rt)
    • Hypergraphia (Rt)
    • Ruminative intellectual (Lt)
  • However, “current data do not support or refute any consistent clustering of behavioural traits in epilepsy” Devinsky 1996
  • But may show extremes and diversity.

Aggression and Epilepsy

  • Aggression - ictal, possibly ictal, not ictal
  • Ictal:  usually part of confusion, poor handling etc
  • Very rare as part of an automatism
  • Poorly directed, fragmentary, simple, brief,
  • Repetitive, lack of concealment, remorse after
  • Possibly ictal: ? “Episodic Dyscontrol”
  • Not ictal: statistical relationship between epilepsy and
  • Violence for various epidemiological reasons.