Emotional Changes Behavioural and Emotional Changes in Persons with Epilepsy By Kristen Lamertz Can having epilepsy affect one's emotions and behaviour? Concerns about the effect of having recurring seizures on an individual's emotional state and behaviour are often raised. The vast majority of persons with epilepsy have no more emotional baggage to carry than the next person. Some people who have seizures, though, may experience more extreme emotional changes or exhibit behaviours which are not considered socially acceptable. What can causes such changes to emotions and behaviour? In most cases such changes are caused by the strains of dealing with our society's often hostile attitudes toward disability in general and epilepsy in particular. Sometimes, though, medication and the seizures themselves may affect a person's emotional state and her or his behaviour. The following paragraphs will offer a brief discussion of each of the three main contributing factors to emotional and behavioural changes in persons with epilepsy: psychosocial circumstances, medication, and seizures. Psychosocial Circumstances What are some common feelings that people with epilepsy experience? For the person with epilepsy, a range of factors can combine to produce a heightened sense of anxiety, depression, low self-esteem, and feelings of isolation. While most people with the condition learn how to deal with these feelings, some may respond to such pressures by reacting in an overly aggressive, asocial, irritable, or introverted manner. Can the fear of having a seizure cause emotional and behavioural problems? It is often the possibility of having a seizure, rather than the seizure itself, which may be handicapping to the person with epilepsy. Afraid of having a seizure in public and the very real possibility of injury, the person with epilepsy may seclude her- or himself. As a result a person may become very isolated. As well, the person with seizures may be anxious about other people's reactions to a seizure. Many people who witness a seizure may react by being afraid and embarrassed by the situation. Since the individual who has seizures has no control over other people's reactions during a seizure, he or she may prefer to stay alone and in isolation. What effects can feeling 'out of control' have? One of the greatest concerns for the person, who has recurring seizures, is the perceived loss of control, which goes along with having seizures. Contemporary western culture has glorified the image of the controlled and independent adult. The unpredictability of having a seizure, as well as the very obvious loss of control during seizures clearly does not reflect this image. By thus "failing" to meet the basic standards of our culture, a person's sense of self-worth may well be affected. This sense of not being in control may also extend to include other aspects of a person's life. What affect can the public's misunderstanding of epilepsy have on person with epilepsy? Being stigmatized for having epilepsy is also an important aspect. Popular misconceptions about epilepsy are still widespread. Again, other people's negative responses may considerably add to the stress of the person with epilepsy and may lead them to choose isolation over social interaction. How important is accepting one's own epilepsy? Sometimes, if the condition is well controlled, and a person has only a few seizures, he or she may not feel compelled to deal with the condition. Then, the denial of the condition can compound feelings of anxiety. In a sense, the person does not get "used" to having seizures, and each seizure becomes yet another traumatic experience. A person's own attitudes towards having seizures can also very much influence their emotional state. By not accepting the reality of having seizures, some persons may go through some length to hide it from the people around them. The anxieties of possibly being found out may reinforce the desire to socially isolate themselves. What other factors can increase emotional stress? Another important factor for the person with epilepsy that can greatly increase stress and thereby emotional strain is economic hardship. High rates of unemployment and underemployment --more than 50% for persons with seizures-- severely restricts the income of many people with epilepsy. Thus they may have difficulty sustaining a household, not to mention the added expenses of anti-convulsant medication.   Medication Can anti-convulsant medication affect emotions and behaviour? Most persons who take anti-convulsant medication to control their seizures do not experience serious and intolerable side effects from it. In some cases, however, the side effects from taking medication may affect an individual's behaviour and/or emotional state. Such changes may include an impairment of drive, mood, sociability, alertness, or concentration. People who experience side effects in response to taking one single drug will generally find that these effects will disappear over the first few months. However, side effects may become a problem when the person is taking more than one kind of anti-convulsant medication, to control different types of seizures. It may be that the side effects of one medication are compounded by the side effects of another. If these effects are not well tolerated, changes in behaviour and mood can occur. However, it has been found that, if the amount of medication an individual receives is reduced, these changes are reversed. While it is important to be aware of the possible effects of medication, it should be recognized that they do not usually present a serious problem to adults with epilepsy as long as they are administered in the appropriate dosage. Seizures Can the seizures themselves affect emotions and behaviour? The place in the brain where seizures originate may also have an effect on a person's emotions and on her or his behaviour. Seizures with temporal lobe involvement, complex partial seizures (formerly known as psychomotor or temporal lobe epilepsy) are most commonly associated with behavioural changes. Such changes can include rapid fluctuations in mood, or over-attention to detail. Studies reporting on this relationship, however, do not agree at all on its nature. While a consensus does exist that temporal lobe involvement in epilepsy can affect behaviour, researchers have not found that any prediction can be made either to the type of change which occurs, or to the certainty with which behaviour will change within the population of persons with complex partial seizures. Can head injuries affect emotions and behaviour? Head injuries, which are sometimes the underlying cause for a person's seizures, can also be associated with behavioural and emotional changes. However, since these changes are separate from a person's epilepsy, they have not been addressed here. What is most likely to cause emotional or behavioural problems? When considering the effect of having epilepsy on a person's emotional and behavioural state, it is important to remember that all the above factors may interact with each other to produce an overall set of pressures acting on the person. Most people with epilepsy have no more trouble dealing with their feelings than others who do not have seizures. Even for those persons who do experience excessive emotional instability however, the cause for these lies most often in having to deal with an under- or misinformed society, rather than in the medical aspects of having epilepsy. The often hostile reactions, which the person with seizures has to deal with, can lead her or him to withdraw and isolate her- or himself from society. As a result, the person with seizures may appear to be asocial or antagonistic.   Suggested Reading Bouchard, I. "The Main Problems Encountered by People with Epilepsy: Description and Development." In Aiming at a Healthier Life. Montreal: Health and Welfare Canada, 1990. Fenton, G.W. "Personality and behavioural disorders in adults with epilepsy." In Epilepsy and Psychiatry. Eds. E.H. Reynolds and M.R. Trimble. London: Churchill Livingstone, 1981. Goldin, J.G., Margolin, RJ. "The Psychosocial Aspects of Epilepsy." In Aiming at a Healthier Life. Montreal: Health and Welfare Canada, 1990. Goldstein, J., Seidenberg, M., Peterson, R. "Fear of Seizures and Behavioural Functioning in Adults with Epilepsy." In Journal of Epilepsy. Vol. 3, No. 2, 1990. pp.101- 106. Masland, R.L., Aird, R.B., Woodbury, D.M. The Epilepsies: A Critical Review. New York: Raven Press, 1984. Reynolds, E.H., Trimble, M.R. "Adverse Neuropsychiatric Effects of Anticonvulsant Drugs."In Drugs. Vol. 29, No. 6, June 1985. pp. 570-581
Memory Problems Strategies on How to Cope: Notes from a lecture by Clare Brandys, Ph.D., C.Psych., Psychologist, Clinical Neuropsychology. Note: This information provides general principles only. For more elaborate and individualized information it is recommended that interested people contact their own health care providers. Why do people with epilepsy often have memory problems?  Your memory process can be interfered with by epileptic seizures. Or an underlying disorder in the brain, which causes the seizures, may be what is disrupting the memory process. It may be the effects of your anti-epileptic medication. Or it may not actually be a memory problem at all. How can seizures cause memory problems?  Memory is a natural brain process that requires continuing attention and recording by parts of the brain. Seizures interfere with memory by interfering with attention or input of information. Confusion often follows a seizure, and during this foggy time new memory traces are not being laid down in the brain. Tonic-clonic (grand mal) seizures in which you lose consciousness can interfere with normal brain processes and disrupt the registration phase of short-term memory. Sometimes longer term memories from the period prior to the seizure are lost as well, as these memories may have not yet being fully integrated into the brain’s memory system. If a seizure is very severe and prolonged (status epilepticus) and you experience hypoxia (insufficient oxygen to the brain), this can cause secondary damage to your memory system. What else can cause memory problems?  An underlying brain tumour or lesion can disrupt the memory process. Or if the focus of your seizures is located deep in the temporal lobe of your brain near some of the parts that are important for memory (e.g. the hippocampus), this may be causing your problem. Some people with epilepsy have unusual electrical activity in their brains between seizures - what is known as "inter-ictal" or "sub-clinical" activity. This can interfere with attention and also, probably, with memory. Or perhaps you are experiencing a cognitive problem (e.g. an attention problem, language problem, or a visual/spatial problem) and not a true memory problem. Perhaps the problem is emotional and not memory-based, brought on by anxiety in certain situations or by depression. Your ability to recall may be interrupted by your mood or by sleep disturbances.   Can anti-epileptic medication cause memory problems?  Anti-epileptic medications may affect your thinking and memory, but on the other hand, they may control your seizures, and having lots of seizures can lead to more memory loss. Discuss the side-effects of your medication with your neurologist. Do not stop taking your medication on your own. Are all memory problems the same?  No. Learn more about your specific memory problem. Do you have memory lapses following a seizure? Do you have fluctuations in your memory, where it is better some times more than others? Are the fluctuations related to stress, or to certain kinds of tasks or situations? For example, is your memory worse when you are in a particular place or with a particular person? Many kinds of memory problems are stress-related. Can you remember things if you are given a prompt or cue? Do you have a better memory for pictures (visual type memory) than words (verbal type). Memory is lots of different processes. Learn which ones you rely on in order to maximize your strengths and accept your limitations. What are the processes of memory?  There are many different ways to classify how memory works. Some people rely more on their verbal memory, remembering in terms of words or sounds, whereas others use their visual memory, relying on pictures or spatial relationships. Which process works best for you? There is semantic memory, referring to knowledge-based memory of a particular topic, like the history of World War I, for example. This differs from episodic memory, or memory of a particular event, such as an outing you were on last week. Most of us have heard of short-term (or working) memory vs. long-term memory, which really refers to the memory of things in the recent past.  Getting the information into our memory is called the encoding and then the consolidation process, and the separate process of getting it out again is called retrieval. Some people have a problem getting information into their memory in the first place, whereas others find the retrieval challenging, and may just need a cue or prompt before they are able to retrieve a memory. Start to notice which memory processes are working well for you so you can play to your strengths and minimize your weakness. Do my emotions play a role in my memory problems?  Try to learn more about how you operate. There may be situations that are important to you where your memory problems keep interfering, but there are other situations of less value to you when it should be less of an issue. What are the demands on you and what do you do? You may be making your problem worse by being mad at yourself when you can’t remember something. If you make a memory mistake, don’t fight it and impair your cognitive skills further, just move on. Trying harder usually won’t help you remember. An emotional attitude of acceptance and accommodation is more beneficial to memory than self-defeating behaviours or thoughts. Chances are your memory problem is not going to go away, so keep your expectations reasonable and look at ways to work around the problem. What are the most common everyday memory problems?  According to one survey of the five most common memory problems, first is being unable to come up with a word that we feel is "on the tip of our tongue", apparently because of a verbal memory processing problem. Second is having to go back to check to see if something was done, such as turning off the stove, probably reflecting a failure to pay adequate attention at the time. Third is forgetting where we put something, probably a visual-spatial memory process problem. Forgetting the name of someone or thing is fourth, apparently a verbal memory malfunction. Not remembering what has been said or been told is another. The types of problems people have vary, and how serious a nuisance the problems are varies from person to person as well. Do memory problems ever improve over time?  If your memory problem is the product of a newly acquired brain injury, you may have a period of spontaneous recovery as the brain cells reorganize during the period right after your injury. However, if more than a couple of years have elapsed since a brain injury, significant change is not expected, and after two or three years all the recovery will likely be completed. If your memory problem is rooted in something that happened 20 years ago, a natural recovery is unlikely at this point. Accepting that there is no "cure" for such memory problems is important. But strategies can still help you work around the problem. Can memory be improved through mental exercises?  Staying mentally active is a good thing, but it won’t really help your memory problem. Research has shown that playing memory games or doing exercises to sharpen your memory doesn’t help your memory in general. Memory is not a muscle: exercising it doesn’t work. What is more useful is developing techniques and strategies to help you cope with your memory problem. What can I do to live better with a memory problem?  Memory coping is about good memory habits, developing a healthy "memory diet" (like the four food groups). Improved results can occur if you allow the type of memory that works best for you to compensate for another type; for example, using pictures to help you remember if your visual memory is stronger. Use consistency, and control what you can to make remembering easier. Telling other trusted people that you have a memory problem is an excellent technique-they can help by cueing you. Just saying, "I tend to forget that, I would appreciate it if you would give me a reminder" can make all the difference in the world. Don’t be afraid to rely on others. Recognize that your mood and stress can contribute to memory problems. Keep your expectations for yourself reasonable. And be flexible in your approach to fit the memory demands on your memory. What are some good memory habits? "Accept (that one) cannot...cure use remaining capacities pay more attention spend more time repeat make associations organize link input and retrieval" -Berg et al, 1991 What are some formal strategies for helping the memory process itself?  The memory process consists of getting the information in, keeping it in, and then getting it out again. You can actively work on getting the information in-encoding it-by simply paying close attention to the specific things you want or need to remember. Many people have problems remembering the name of someone new because at the time, they aren’t really paying attention to the name itself. Distractions get in the way of really attending to new information, so cut out distractions wherever possible. Repeating or rehearsing the information-saying it more than once-- will help encode it. Elaborating on it, exaggerating it, organizing it, or associating it with something else meaningful to you are other ways we increase its impact on our memory processes. For instance, you may take someone’s name and make up a whole outrageous picture or elaborate association with something else it reminds you of. These techniques help our brain to process the information on more than one level and to make more connections. Research shows that the memory trace is stronger if it has more connections in the brain-- the information will simply stick better. Chunking or breaking down information-- a telephone number, for example-- into smaller, easier to remember "chunks" is another strategy for more effectively encoding material.  I recommend The Page a Minute Memory Book by Harry Lorayne for lots of simple and practical day-to-day memory strategies.   What are some other formal memory strategies?  Lots of material lends itself to using mental pictures or imagery to help us memorize it, especially if your visual memory is what works best for you. You can use "pegs" to help you memorize a sequential list. With the peg method, each number has a rhyming visual cue, for example "One, bun, Two, shoe, Three, tree, Four door," and you visualize the first thing you want to remember on a bun, etc. The more of your senses or modalities you use, the more likely you are to remember it. For instance, writing out someone’s name will help you remember it, but writing it in sand (touching it) as well as hearing it would "cross code" it and make it more likely to "stick". Some people find first letter clues help them memorize lists, like "Every Good Boy Deserves Fudge" for the musical scale EGBDF. Other people weave information into a "story" that uses elaboration, exaggeration and visualization-- cross coding it to help them remember. What are Memory Groups?  Groups of people who get together and support each other’s use of memory strategies are called "Memory Groups". These can be very helpful to people who find they are not coping well with their memory issues or who want to share experiences with others. Will using natural remedies help my memory?  Natural herbal remedies for memory are unproven. Some people take a substance called Gingko Biloba for their memory. My position is that I can’t specifically recommend Gingko Biloba, although as far as I know it is not harmful. Another natural remedy is Ginseng, which, as a stimulant, may help alertness, which is a part of the memory process. Certainly, we learn better when attentive. Make sure your epilepsy doctor knows what substances you are taking, if any. How can I take control of my memory problem?  Acknowledge that you have a memory problem. Presume that you will have a memory problem tomorrow. You have got this, so live with it as best you can. Don’t set yourself up for defeat. If you think that you are likely to forget something, don’t test yourself to see if you do. Instead, do what you can to reduce the number of things you have to remember. You can restructure your environment so you don’t have to use your memory as often. Use external aids to help you. For instance, if you want to remember to take something with you when you go out, put it by the door when you think of it so you don’t have to remember it later. Put signs and labels on things so you don’t have to remember them. Take control of your world. Who cares if you don’t get everybody’s name right?   What other external aids can I use?  Write things down in a diary, notebook, calendar or list so you don’t have to remember it again. Or record them on a portable tape recorder or dictaphone while you are thinking of them. Employ sensory cues to remind yourself to do something: a beeper, alarm watch, or simply tie a string around your finger (as long as that cue is specific enough for what you have to remember!). Technology can be a great help with new devices like electronic organizers, watches that record phone numbers and the new Neuropage system that tells you when to take your medications, etc. How can I enjoy reading books when I forget what I’ve just read?  This can be a challenge. Try reading out loud to help you pay closer attention to what you are reading. Or use a highlighter to visually exaggerate certain key phrases as you read. Or try taking notes as you go along. Translating what you have just read into your own words can help commit it to memory. Make a special point of including it in a conversation soon after you’ve read it. Exaggerate it to strengthen the memory trace. What hints can you give someone with memory problems?  Memory coping is about good habits and working around the problem. Try to relax: stress may make your memory worse. Be flexible: different types of information may require different memory methods. Be committed, motivated: paying more attention takes effort. Try again if one method fails: things may not turn out as you planned. Try not to dwell on all the things from the past that you wish you could remember. Pay attention to what is going on now so you can make some new memories. Look ahead, not behind. And... celebrate your memory successes!!
Psychiatric Disorders Associated with Epilepsy Authored by William J. Nowack, M.D., Associate Professor, Department of Neurology, University of South Alabama William J Nowack, MD is a member of the following medical societies: American Academy of Neurology, American Clinical Neurophysiology Society. American Epilepsy Society. American Medical Eledroencephalographic Association, and American Medical Informatics Association.        Edited by Andrew S Blum, MD, PhD, Instructor, Division of Clinical Neurophysiology, Department of Neurology, Beth Israel Deaconess Medical Center; Francisco Talavera, Pharin D, PhD, Creighton University, Department of Pharmacy; Jose E Cavazos, MD, PhD, Assistant Professor, Department of Neurology, University of Colorado Health Sciences Center; Selim R. Benbadis, MD, Director of Epilepsy Program, Associate Professor, Departments of Neurology and Neurosurgery, University of South Florida College of Medicine; and Helmi L. Lntsep, MD, Associate Director of Oregon Stroke Center, Assistant Professor, Department of Neurology, Oregon Health Sciences University.         INTRODUCTION    Both neurology and psychiatry deal with diseases of the same organ, the brain. It is therefore not unreasonable to predict that there would be interaction between neurological and psychiatric diseases.  In an editorial in Neurology Price, Adams and Coyle (2000) explored these interactions. The clinical relationship between epilepsy and behavioral disorders remains controversial.     ·        Some authors find a greater incidence of behavioral disorders in epileptics than in the general population. ·         Other authors argue that this apparent over-representation is due to sampling errors or inadequate control groups. (Smith and Darlington, 1998)     Mechanisms for such a relationship include:   ·        common neuropathology ·        genetic predisposition ·        developmental disturbance ·        ictal or subictal neurophsyiological effects ·        inhibition or hypometabolism surrounding the epileptic focus ·        secondary epileptogenesis ·        alteration of receptor sensitivity ·        secondary endocrinological alterations ·        primary, independent psychiatric illness ·        consequence of medical or surgical treatment ·        consequence of the psychosocial burden of epilepsy (McConnell and Snyder, 1998)    Because of the phenomenology of epilepsy, there is a long history regarding the close association between epilepsy and psychiatry (Duffy, 1998). The traditional approach to epilepsy care has been to focus on the seizures and their treatment Concentrating only on the treatment of the seizures, which occupy only a small proportion of the epileptic's life, does not seem to address many of the issues which impact adversely on the epileptic patient's quality of life. Sackellares and Berent( 1996) state that comprehensive care of the epileptic patient requires "...attention to the psychological and social consequences of epilepsy as well as to the control of seizures."  Although undoubtedly important in the care of the epileptic patient, advances in the neurologic diagnosis and treatment tended to obscure the behavioral manifestations of epilepsy until Gibbs(1951) drew attention to the high incidence of behavioral disorders in patients with temporal lobe epilepsy. There is general agreement that there is a higher incidence of neurobehavioral disorders in populations of patients with epilepsy than in the general population. Many, but not all, authors also accept the proposition that the link between temporal lobe, or complex partial,epilepsy is particularly strong. Edeh and Toone (1987) feel that the difference is between focal epilepsies, both temporal lobe and non-temporal, lobe versus primary generalized epilepsy. ·        Vuilleumier and Jallon (1998) estimate that 20% to 30% of epileptics have psychiatric disturbances ·        Tuclcer(1998) reports that one study found that 70% of patients with intractable complex partial seizures had DSM-III-R diagnoses ·        58% had a history of depressive episodes ·        32% bad agoraphobia without panic or other anxiety disorder ·        13% had psychoses ·        Torta and Keller(1975) report that the risk of psychosis in populations of epileptics may be six to twelve times that in the general population with a prevalence of about 7-8% (in treatment refractory temporal lobe epileptics, the prevalence has been reported from 0-16 %). ·        Differences in the rates may result from differences in populations studied, and time periods investigated, diagnostic criteria. In studying the relationship between epilepsy and psychiatric disorders, care must be taken to differentiate between ·        Psychiatric disorders caused by the seizures of the epilepsy ·        Ictal disorders ·        Postictal disorders ·        Interictal disorders ·        Epileptic and psychiatric disorders that are caused by common brain pathology ·        Epileptic and psychiatric disorders that happen to coexist in the same patient but are not causatively related.   ·        Schmitz and co-worker’s (1999) found that biological and psychosocial risk factors for the development of either schizophrernform psychoses or major depression in epileptics were linked, suggesting multiple risk factors and multi-factorial etiology ·        The psychiatric symptoms characteristic of the neurobehavioral syndrome of epilepsy (Morel's syndrome) tend to be distinguished by being ·        atypical for the psychiatric disorder ·        episodic ·        pleomorphic (Blumer, 1991)       PSYCHOSIS ·        Vuilleumier and Jallon (1998) found that 2% to 9% of epileptic patients have psychotic disorders ·        Perez and Trimble (1980) felt that about half of the epileptic patients with psychosis could be diagnosed with schizophrenia ·        Ictal events: Status epilepticus can mimic psychiatric disorders, including psychosis ·        Complex partial status epilepticus ·        Absence status epilepticus   Postictal events:     ·        Soetal. (1990) distinguish between postictal psychosis, which is characterized by well systematized delusions and hallucinations in a setting of preserved orientation and alertness, and postictal confusion and also between the self limited postictal psychosis and the unremitting chronic interictal psychosis seen in long-standing epilepsy ·        Criteria proposed by Stagno(1997) for postictal psychosis are: ·        Psychotic or other psychiatric symptoms occur after a seizure or, more frequently, a series of seizures ·        After a lucid interval ·        Within seven days of the seizure(s) ·          ·  The event may be:     ·        Psychosis ·        Depression or elation ·        Anxiety related symptom ·        Event is time limited, lasting days and rarely weeks ·        No significant clouding of consciousness ·        Logsdail and Toone (1988) feel that there may be clouding of consciousness, disorientation or delerium and that if consciousness is unimpaired there needs to be delusions and hallucinations; there may be a mixture of both. ·        Not attributable to other medical or psychiatric cause (e.g. drug intoxication, complex partial status epilepticus, metabolic disturbance) ·        Interictal psychosis ·        Tandon and DeQuardo (1996) reviewed the series of epileptics who developed psychosis published by Slater and Beard and found that the psychosis was usually a form of schizophrenia, most commonly paranoid schizophrenia ·        Stagno (1997)feels that persistent interictal psychoses of epilepsy, or the "schizophrenia-like psychoses of epilepsy" are distinguished from schizophrenia in traditional psychiatric sense by ·        lack of negative symptoms of schizophrenia, particularly flattening of affect and personality deterioration ·        better premortrid personality ·        parooid delusions ·        delusions of reference ·        more benign and variable course ·        Risk factors for developing psychosis in epilepsy which have been found in some studies include: ·        partial complex seizures, especially with ·        temporal lobe foci ·        some authors have noted a predominance of left sided foci ·        frontal lobe epilepsy is also common ·        the presence of "alien issue" (e.g. small tumors, hamartomas)(Taylor, 1975) ·        mesial temporal lobe gangliogliomas (Roberts and co-workers, 1990) ·        left handedness, especially in women ·        Schmitz (1999) and co-workers studied risk factors and found ·        Biological factors ·        Earlier onset of epilepsy ·        More severe epilepsy ·        Temporal lobe and unclassifiable epilepsies more fiequent and generalized epilepsies less frequent but no significant differences in types ofepilepsies between epileptics with psychosis and epileptics without psychiatric disease ·        simple partial seizures more frequently vegetative ·        Psychosocial factors ·        disturbed familial background ·        lack of interpersonal reltionships ·        social dependency ·        professional failure ·        Treatment     ·        Status epilepticus and ictal abnormalities are treated in the same way as non-psychiatric epileptic events are treated ·        Postictal events are treated with better seizure control; So and co-workers (1990) feel that postictal psychosis remits spontaneously even without treatment but that the use of effective neuroleptics may shorten the duration ·        Interictal psychosis is treated with anti-psychotic drugs ·        Medications which lower seizure threshold should be avoided ·        Some studies indicate that risperdone, molindone and fluphenazine may have better profiles than older anti-psychotic medications; clozapine has been reported to have a particularly high risk of seizures (Stagno 1997) ·        Treatment of any of the psychoses of epilepsy should take into consideration the phenomena termed forced normalization ·        Forced normalization is a concept described by Landolt in the 1950's. When the EEG in psychotic patients is normalized, often with anticonvulsant medicines, the psychiatric problem worsens (Wolf, 1991) ·        As alternative psychosis, antagonism between seizures and behavioral abnormalities (worsening of behavior with improvement in seizure control) a similar phenomenon has been known for a longer time (Trimble and Schmitz, 1997) ·        forced normalization is most frequently described with ethosuximide but aim ecdotally forced normalization effects have been produced by treatment with most antiepileptic agents, including the newer agents (Krishnamoorthy and Trimble, 1999) ·        The mechanism underlying these interesting phenomena is not as yet understood (Krishnamoorthy and Trimble, 1999)     MOOD DISORDERS     ·        Depression ·        Depression is a not uncommon problem in patients with epilepsy (Mendez et al., 1986) ·        Hippocrates noted the association "Melancholics ordinarily become epileptics and epileptics melancholics." (Robertson, 1998) ·        In a study of epileptic patients admitted to a psychiatric hospital, Betts found that depression was the most common psychiatric diagnosis (Stevens, 1991) ·        The frequency of anxiety has also been commented on (Blumer and Altshuler, 1997) ·        Two possibilities are that the depression is a reaction to the chronic illness and that the depression is part of the epilepsy ·        Mendez and co-workers (1986) compared epileptics to matched non-epileptic controls with similar degree of disability from other chronic medical diseases ·        They found that 55% of the epileptics and only 30% of the matched controls reported depression ·        They concluded that the depression is related to a specific epileptic Psycho-syndrome      On the other hand, Robertson (1998) has concluded that, with a few exceptions the phenomenology of the depression is not to a large degree, attributable to neuro-epilepsy variables. ·        Not all studies have found that difference, however (Blumer and Altshuler, 1997) ·        The etiology of depression in people with epilepsy is complex and includes ·        genetic vulnerability ·        reaction to life events, including the epilepsy ·        effect of anti-epileptic drugs ·        the epilepsy, particularly temporal lobe complex partial epilepsy(Robertson, 1997) ·        Characteristics of epileptics with depression which have been reported include ·        Fewer neurotic traits (Mendez et al„ 1986) ·        More psychotic traits (Stagno, 1996) ·        Higher trait and state anxiety scores (Robertson et al.,1987) ·        More abnormal affect and chronic dysthymic disorder (Mendez et al. 1986) ·        High hostility scores, especially for self-criticism and guilt (Lambert and Robertson, 1999) ·        Sudden onset and brief duration of symptoms (Blumer and Altshuler, 1997) ·        Risk factors for the development of depression in patients with epilepsy include ·        Temporal lobe and not frontal lobe partial complex seizures (Schmitz et al., 1999) ·        Vegetative auras (Schmitz et al., 1999) ·        Family history of psychiatric illness, particularly depression (Lambert and Robertson, 1999) ·        Lateiality effects are controversial ·        Flor-Henry speculated that depression might be related to right (nondominant) foci ( 1969), a finding confirmed by a few other investigators (Lambert and Robertson, 1999) ·        Some authors suggest that elation is associated with right sided lesions and depression or sadness with left sided lesions (Robertson, 1998) ·        Most studies that find a relationship between laterality and depression have found depression to be more common with left sided foci (Lambert and Robertson, 1999) ·        Some authors found no laterality differences in deptession rates (Blumer and Altshuler, 1997) It is useable to break depression in patients with epilepsy down into depression occuring peri-ictally (pre-ictally, ictally or postictally) and that occurring interictally ·        Robertson argues that Julius Caesar may have had depression as part of his seizures (1998) ·        Denis Williams studied 2000 patients with epilepsy and found that depresed mood as part of the attack in 21, the second most common emotion as part of the atack. Fear was the most common; others have found similar results (Blumer and Altshuler, 1997) ·        Perhaps 10-20% of epileptics have a peritotal prodrome consisting of depressed-irritable mood, sometimes with anxiety or tension and headaches (Blumer, 1991) ·        Although Williams noted in his patients that the mood disturbance would persist for from I hour to 3 days after the ictus (Blumer, 1991) postictal affective syndromes have also received little attention in the literature (Blumer and Altshuler, 1997) ·        Blumer has defined an interictal dysphoric disorder (IDD) in patients with epilepsy where ·        Symptoms tend to be intermittent ·        On the average patients tend to have five of the following symptoms (average three to eight)   Depressed mood Anergia Pain Insomnia Fear Anxiety Paroxysmal irritability Euphoric moods   Treatment   ·        The treatment of mood disorders in epileptics includes ·        Re-evaluation of the anticonvulsant regimen ·        Cautious but aggressive use of antidepressants ·        Psychotherapy may also be of use (Stagno 1996) ·        Improvement in seizure control should help in the treatment of ictal depression (Lambert and Robertson 1999) ·        A phenomenon analogous to alternative psychosis, worsening of behavior with better seizure control, has been reported in epileptic-associated mood disorders (Wolf 1991) ·        Phenobarbital is known to produce depression (Robertson 1998) ·        Vigabalrin and phenytoin should also be avoided, if possible (Lambert and Robertson 1999) ·        The suggestion has been made that the GABAergic drugs are associated with an increased incidence of psychiatric problems (Schmitz 1999) ·        Virtually all non-monoanune oxidase inhibiting antidepressants have been reported to lower seizure threshold (Robertson 1998) ·        In the treatment of epilepsy related depression, priority should be given to optimizing seizure control, since improved psychosocial functioning tends to accompany seizure iemission(Schmitz 1999) ·        Antidepresants may manifest convulsant and anti-convulsant effects ·        maprotiline and amoxapine have the greatest seizure risk ·        doxepin, trazodone and fluvoxamme have the lowest risk(Pisani et al. 1999)   Suicide     The risk of suicide in the general population averages about 1.4%(Robertson 1997) Depression is one of the psychiatric disorders that increases the risk of suicide. It is generally felt that the risk of suicide in depressed patients is around 15%. In a recent study of over 9000 manic-depressive patients, a suicide rate of 18.9% was found (Roy, 1995). Pokorny (1966) has estimated that the risk of suicide in depressed patients is as high as fifty times that of the general population On average, the risk of suicide in patients with epilepsy is about 13% (prevalence rate between five and ten times that of the general population) (Robertson, 1997) Although some authors question the report on methodological and patient selection grounds (Stevens, 1991), most authors cite Banaclough's meta-analysis finding that the risk of suicide in patients with temporal lobe epilepsy is increased as much as 25-fold (1981)   Mania     ·        The best know examples of perictal elated mood are Dostoevsky's descriptions of ictal experiences in his works “The Idiot and The Possessed” (Robertson, 1998) ·        In a carefully selected series of epileptic patients, Williams (1956) found only 165 of 2000 had complex, including emotional, ictal experiences. Of those 165, only 3 described elation ·        Mania and hypomania are also rare in association with epilepsy(Robertson, 1998) ·        Manic-depressive illness is also rare; of 66 epileptics with major depression, only 2 had bipolar disease (Robertson et al., 1987) ·        Possibly to some degree this rarity is secondary to the antimanic effect of such drugs as cabamazepine and valproate (Robertson. 1998). Mania was uncommonly associated with epilepsy even before the use of modem antiepileptics (Blumer and Altshuler, 1997)   ANXIETY DISORDERS     Anxiety in epileptic patients may occur: 1.      as an ictal phenomenon 2.      as an interictal normal emotion or part of an accompanying anxiety disorder 3.      as part of an accompanying depressive disorder 4.      in association with non-epileptic seizure-like events as part of an underlying primary anxiety disorder (McConnell and Duncan, 1998)     Anxiety is common in epileptics     ·        In 49 epileptic patients attending a tertiary epilepsy care center, 57% had high state anxiety (Francis et al., 1996) ·        In temporal lobe epileptics, Trimble and co-workers (1996) report that 19% were diagnosed with anxiety and 11% with depression ·        Edeh and Toone (1987) found that temporal lobe epileptics scored higher for anxiety than focal, non-temporal lobe epileptics ·        Because of the difficulty separating the anxiety that accompanies a chronic disease from pathologic anxiety, there have been relatively few studies of anxiety in epilepsy (Stagno, 1996) ·        Fear and anxiety are often associated with simple partial seizures (Torta and Keller, 1999) ·        It can be difficult to differentiate between spontaneous fear and reactive fear (the reaction to the knowledge that a seizure may occur) ·        Panic disorder, which can produce paroxysmal symptoms which can be confused with epileptic events, may go unrecognized in epileptic patients (Stagno, 1997) ·        Anxiety may also be related with non-epileptic attack disorder (Torta and Keller, 1999)        PERSONALITY DISORDERS     The question of personality disorders associated with epilepsy has a long history and remains controversial. 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