1. • Neuropsychiatric aspects
of
epilepsy
•
•
•
•
•
•
•
•
•
•
Presenter
Dr Mohd Osman Ali
Scheme of presentation
Overview of epilepsy– epidemiology, terminology, mechanism, types, classification,
diagnosis, investigations
Introduction to psychiatric manifestations of epilepsy– epidemiology, different
manifestations
Ictal features
Perictal features--Prodromal symptoms, Postictal confusion, Peri-ictal psychoses
Interictal features-- Schizophreniform psychosis,Personality disorders, GastautGeschwind syndrome
Behavioral Disturbances Variably Related to Ictus-- Mood
disorders,Anxietydisorders, Aggression, Hyposexuality, Suicide, Other behaviors
Management implications
Over view of epilepsy
•
•
•
Epidemiology of epilepsy
Epilepsy affects 20 to 40 million people worldwide
and has a prevalence of at least 0.63 percent and an annual
incidence of approximately 0.05 percent.

2. •
•
•
•
•
•
The overall incidence is high in the first year, drops to a minimum in
the third and fourth decades of life, then increases again in later
life.
12 to 20 percent have a familial incidence of seizures.
Among adults, the most common seizures are complex partial and
generalized tonic-clonic seizures.
Etiology and pathology
Most new-onset epilepsy is idiopathic,
but other frequent causes include
–
–
–
•
•
trauma in the third and fourth decades of life,
neoplasms in the fifth and sixth decades of life,
and cerebrovascular disease in the elderly.
Although some complex partial seizures originate
from the frontal or temporal neocortex and
other areas,
at least two-thirds of complex partial seizures
and generalized tonic-clonic seizures originate
from the mediobasal temporal limbic structures
(hippocampus, amygdala, and parahippocampal
gyrus).

3. •
•
•
•
•
•
•
Terminology related to epilepsy
Epileptic seizures are sudden, involuntary
behavioral events associated with excessive or
hypersynchronous electrical discharges in the
brain.
Epilepsy is the recurrent tendency to seize,
status epilepticus is prolonged or repetitive
seizures without intervening recovery.
The seizure itself is known as the ictus.
The interictal period refers to the period
between the postictal abnormalities and the
next ictus, and
the peri-ictal period refers to the period just
before or after the ictus
–
•
and is applied when there is insufficient
information to know when the ictus ends or
begins.
Mechanism of Epilepsy

4. •
In epilepsy, abnormal electrical discharges are
due to hyperexcitable neurons with sustained
postsynaptic depolarization.Proposed
mechanisms
–
–
–
•
•
•
•
•
•
changes in ionic conductance,
decreased γ-aminobutyric acid (GABA) inhibition
of cortical excitability,
and increased glutamate-mediated cortical
excitation.
Types of Epileptic Seizures
primary
secondary to a neurological condition, or
reactive to a situational factor, such as sleep
deprivation or drug withdrawal
International Classification of Epileptic Seizures
Partial (focal, local) seizures
–
Simple partial seizures
•
–
Motor, somatosensory, autonomic, or psychic
symptoms
Complex partial seizures

5. •
•
•
•
•
•
•
Begin with symptoms of simple partial seizure but
progress to impairment of consciousness
Begin with impairment of consciousness
Partial seizures with secondary generalization
Begin with simple partial seizure
Begin with complex partial seizure (including those
with symptoms of simple partial seizures at onset)
International Classification of Epileptic Seizures
(contd..)
Generalized seizures (convulsive or
nonconvulsive)
–
–
–
–
–
–
Absence (typical and atypical)
Myoclonus
Clonic
Tonic
Tonic-clonic
Atonic/akinetic
•
Unclassified
•
Partial seizures

6. •
•
are complex partial seizures (psychomotor or
temporal lobe epilepsy) or simple partial
seizures,
depending on whether there is complex
symptomatology, such as
–
–
•
•
•
•
•
an alteration of consciousness
or psychic symptoms (table psychic auras).
Simple partial seizures
produce isolated motor, sensory, autonomic,
psychic, or mixed symptoms in a clear
sensorium.
Simple partial seizures that evolve to complex
partial seizures are considered auras
Complex partial seizures
are usually characterized
–
by motionless staring combined with simple
automatisms, or
–
–
automatic motor activity,
and last approximately 1 minute.

7. •
•
•
•
Complex partial seizures that evolve to
generalized tonic-clonic seizures are secondarily
generalized.
Generalised seizures
In adults, most generalized seizures are tonicclonic seizures (grand mal seizures or
convulsions)
and are characterized by
–
–
•
•
•
•
an abrupt loss of consciousness
with tonic rigidity followed by a synchronous,
clonic release
absence (petit mal) seizures
which occur less commonly in adults and
are characterized by brief lapses of
consciousness.
Absence seizures differ from complex partial
seizures in
–
being short (10 s in length) and

8. –
–
–
•
•
•
•
•
•
repetitive;
in lacking auras, postictal confusion, or complex
automatisms;
and in having characteristic 2 to 4 counts per
second spike and wave discharges on EEG
Pathological and laboratory examination--EEG
is the most widely used confirmatory test for
seizures;
however, single EEGs are frequently normal and
must be repeated, particularly with provocative
maneuvers, such as sleep.
Occasionally, CCTV-EEG telemetry for an
extended period of time is necessary to capture
seizure activity.
Normal EEG
Basic waves include
– normal waking alpha waves (8 to 13 Hz),
which are most prominent over the occipital
region,

9. – high frequency beta waves (greater than 13
Hz),
•
•
•
•
•
– and theta waves (4.0 to 7.5 Hz)
– and delta slowing (3.5 Hz or less).
A spike is a sharp transient with a duration of 20
to 70 ms.
Seizures are manifest as multiple spikes or spike
and wave discharges on the EEG
Interictally, single spikes and other markers of
abnormal electrical activity may be seen, often
emanating from a temporal lobe.
Neuroimaging procedures
such as CT scans and magnetic resonance
imaging (MRI),
–
•
can more precisely visualize a seizure focus or
even mesial temporal sclerosis.
PET scans may
–
show interictal hypometabolism around the
temporal seizure focus

10. –
•
•
•
•
•
•
•
•
•
and are also useful in the presurgical assessment
of medically intractable seizure patients.
Neuropsychological examinations
particularly during a Wada's test,
– further help in localizing and lateralizing
memory and language before surgery.
Neuropathology
The common pathological findings in epilepsy are mediobasal temporal lobe lesions.
–
Approximately two-thirds of epileptic adults have a temporal lobe focus, and twothirds of these have mesial temporal sclerosis with pyramidal cell loss in the
hippocampus.
Theories about the cause of mesial temporal sclerosis include
–
–
–
perinatal insults,
dysgenesis,
and kindling from reactive seizures.
Another 20 to 25 percent of those with temporal lobe lesions have tumors, such as
hamartomas and gangliogliomas.
The rest have scars from trauma and other causes or lack a distinct histological lesion.
Diagnostic considerations
Clinicians must distinguish epileptic seizures
from two other transient behavioral events,

11. –
–
•
•
•
•
•
•
•
syncope and
nonepileptic seizures (pseudoseizures).
Syncope
Syncope is a loss of consciousness, usually with
premonitory lightheadedness, autonomic
reactivity, a brief atonic ictus, and little or no
postictal confusion.
Syncope lacks the many characteristic features of
seizures and a clear epileptiform EEG.
Nonepileptic seizures
are involuntary, psychogenically induced spells
that, by definition, mimic many epileptic
behaviors
Differentiating epileptic seizures from
nonepileptic seizures can be extremely difficult,
and even epileptologists are incorrect 20 to 30
percent of the time.
Patients with nonepileptic seizures are
–
most commonly women between the ages of 26 and 32 years
of age

12. –
–
•
with psychological stressors and poor coping skills.
Approximately 10 to 15 percent of these patients have a true
seizure disorder as well, and nonepileptic seizures may result
from the elaborating or “highlighting” of their epileptic
seizures.
Nonepileptic seizures are most commonly characterized by
–
–
unresponsiveness with motor activity that does not fit a typical complex partial or
generalized tonic-clonic seizure
In children, nonepileptic seizures are usually characterized by unresponsiveness,
with violent and uncoordinated movements of the whole body.
•
•
•
•
•
However, every epileptic behavior can occasionally occur, including
tongue biting and incontinence, and nonepileptic events are
especially difficult to differentiate from the atypical motor
behavior of frontal lobe epilepsy.
The most helpful differentiation feature may be an ictal duration
of 2 minutes or more.
In addition, nonepileptic seizures
–
–
–
can often be induced with injections, hypnosis, or suggestions;
and are poorly responsive to antiepileptic medications.
Ultimately, the differentiation may require
–
–
CCTV-EEG telemetry
along with the assessment of the absence of a seizure-induced rise in serum
prolactin levels.
Nonepileptic seizures result from a variety of psychiatric conditions.The most common
psychiatric disturbance among these patients is conversion disorder.
–
•
usually occur in the presence of a witness;
Patients with nonepileptic seizures who have conversion disorder have a high
incidence of prior trauma or sexual or physical abuse.
The remaining patients with nonepileptic seizures have
–
depression,

13. •
•
•
•
•
•
•
–
–
–
–
dissociative disorders,
anxiety disorders,
PTSD, or borderline
or other personality disorders.
Additional diagnoses associated with nonepileptic seizures are
–
–
–
psychosis,
impulse control problems,
and mental retardation.
Nonepileptic Seizures versus Epileptic Seizures-Preceding ictus
Nonepileptic Seizures versus Epileptic Seizures--During ictus
Nonepileptic Seizures versus Epileptic Seizures-after ictus
malingering or feigning of epilepsy
Nonepileptic seizures must be differentiated
from those specifically due to the malingering or
feigning of epilepsy for secondary gain
Epileptic seizures lend themselves to
malingering because of their behavioral and
episodic nature and the lack of consistent
physical or diagnostic findings.

14. •
Malingered Seizures versus Nonmalingered
Nonepileptic Seizures--Preceding ictus
•
Malingered Seizures versus Nonmalingered
Nonepileptic Seizures--During ictus
•
Malingered Seizures versus Nonmalingered
Nonepileptic Seizures--After ictus
•
Course and Prognosis
• Most epileptic patients have a good
prognosis. The majority of seizures can
be controlled sufficiently with
antiepileptic medications so that the
patient can live a productive life.
•
Some seizures, such as absence seizures,
tend to disappear by adulthood.
• For epileptic patients who are medically
intractable, epilepsy surgery offers a
good alternative (e.g., temporal

15. lobectomy), provided that the focus can
be localized.
•
In addition, most epileptic patients do
not have psychiatric disorders, and
others have psychiatric difficulties only if
they endure many years of poorly
controlled seizures.
• For those with behavioral problems,
antiepileptic drugs or epilepsy surgery
may relieve some symptoms, such as
hyposexuality and aggression, but may
not affect the emergence of others, such
as psychosis and suicidal behavior.
Introduction to psychiatric manifestations of
epilepsy
•
Epidemiology of Psychiatric manifestations of
epilepsy

16. •
•
Epidemiological studies from communities,
psychiatric hospitals, and epilepsy clinics report a
20 to 60 percent prevalence of psychiatric
problems among epilepsy patients.
Ictal
–
–
•
Prodromal symptoms: irritability, depression, headache, etc.
Postictal confusion
Peri-ictal psychoses
•
Concomitant with increased seizure frequency
• Concomitant with decreased seizure frequency
• Postictal psychoses
Interictal psychosis and personality disturbances
–
–
–
•
Nonconvulsive status: simple partial seizures, complex partial
seizures, and periodic lateralizing epileptiform discharges
Peri-ictal (includes prodromal, postictal, and mixed
ictal)
–
–
–
•
Ictal psychic symptoms
Schizophreniform psychosis
Personality disorders
Gastaut-Geschwind syndrome
Behavioral disturbances variably related to ictus
–
–
Mood disorders (depression and mania)
Anxiety disorders including panic and posttraumatic stress
disorder

17. –
–
–
–
•
•
•
•
Aggression and violence
Hyposexuality
Suicide
Other behaviors
The most established association is between
epilepsy and depression or dysthymia,
These behaviors and others have different
potential relationships to the ictus or seizure
itself
Pathological basis of psychiatric manifestations
Although disputed by some investigators, several
studies report more psychopathology among
epileptic patients than among patients with
chronic diseases that do not directly affect the
brain.
– it would suggest that the psychopathology is
of biological origin rather than a less specific
reaction to chronic disease.

18. •
•
•
•
•
Furthermore, the pattern of behavioral changes
in seizure patients appear specific to epilepsy.
In summary, the psychiatric manifestations of
epilepsy are heterogeneous disorders with
potentially different causes.
Nevertheless, 60 to 76 percent of adults with
epilepsy, regardless of seizure type, have a
temporal lobe focus, and many generalized
tonic-clonic seizures are secondarily generalized
from a temporal lobe focus without a preceding
complex partial seizure.
Moreover, psychic auras from the temporal lobe,
particularly if associated with negative feelings
(e.g., jamais vu and fear), predispose to
psychosis or personality disorders.
Psychiatric disturbances, primarily psychosis and
personality disorders, are two to three times
more common in patients with complex partial
seizures, most of whom have a temporal focus,

19. compared to those with generalized tonic-clonic
seizures;
•
Common neuropathology, genetics, or developmental
disturbance
•
Ictal or subictal discharges potentiate abnormal
behavior
– Kindling or facilitation of a distributed neuronal matrix
– Changes in spike frequency or inhibitory–excitatory balance
– Altered receptor sensitivity, for example, dopamine receptors
– Secondary epileptogenesis
Absence of function at the seizure focus
– Inhibition and hypometabolism surrounding the focus
– Release or abnormal activity of remaining neurons
– Dysfunction or downregulation of associated areas
•
•
•
•
•
•
•
Neurochemical
–
–
Dopamine and other neurotransmitters
Endorphins
Gonadotrophins and other endocrine hormones
Psychodynamic and psychosocial effects of living with epilepsy
–
–
Dependence, learned helplessness, low self-esteem, weak defense mechanisms
Disruption of reality testing
Neurobiological and psychodynamic factors potentiate each other
Sleep disturbance
Antiepileptic drug related

20. •
•
•
•
•
•
•
•
•
1. Common neuropathology, genetics, or
developmental disturbance
Left hemisphere and temporal lobe lesions may
be associated with a schizophreniform psychosis,
and psychosis in epilepsy may be particularly
frequent if there is specific underlying pathology
or ventricular enlargement.
Psychotic disorders may be more common with
temporal dysplasia or neurodevelopmental
abnormalities
and depression with mesial temporal sclerosis.
2. Ictal or subictal discharges potentiate
abnormal behavior
by kindling or facilitating distributed neuronal
connections,
increasing limbic–sensory associations,
or changing the overall balance between
excitation and inhibition.

21. •
Altered receptor sensitivity, for example,
dopamine receptors
•
Secondary epileptogenesis
•
3. Absence of function at the seizure focus
•
•
•
•
•
•
such as the interictal hypometabolism observed
on PET scans, may lead to depression or other
interictal behavioral changes.
Among epileptic patients with a
schizophreniform psychosis, SPECT scans have
shown reductions in cerebral blood flow in the
left medial temporal region.
Release or abnormal activity of remaining
neurons. Dysfunction or downregulation of
associated areas
4. Neurochemical changes
endocrine or neurotransmitter changes, such as
increased dopaminergic or inhibitory
transmitters,
decreased prolactin,

22. •
•
•
•
•
•
•
•
•
•
increased testosterone, or increased
endogenous opioids,
all of which can affect behavior.
5. psychodynamic factors
neurobiological factors may be potentiated by,
such as feelings of helplessness, learned
helplessness, dependency, low self-esteem, and
the disruption of reality testing.
Gen reference articles
Adachi N, Matsuura M, Okubo Y, Oana Y, Takei N: Predictive
variables of interictal psychosis in epilepsy. Neurology.
2000;55:1310.
Bear D, Fedio P: Quantitative analysis of interictal behavior in
temporal lobe epilepsy. Arch Neurol. 1977;34:454.
Dongier S: Statistical study of clinical and electroencephalographic
manifestations of 536 psychotic episodes occurring in 516
epileptics between clinical seizures. Epilepsia. 1959;1:117.
Hermann BP, Jones JE: Intractable epilepsy and patterns of
psychiatric comorbidity. Adv Neurol. 2006:97:367..
Kanner AM, Stagno S, Kotagal P, Morris HH: Postictal psychiatric events during prolonged
video-electroencephalographic monitoring studies. Arch Neurol. 1996;53:258.

23. •
•
•
•
•
•
•
Manchanda R, Freeland A, Schaefer B, McLachlan RS, Blume WT: Auras, seizure focus, and
psychiatric disorders. Neuropsychiatry Neuropsychol Behav Neurol. 2000;13:13.
[*Marsh L, Rao V: Psychiatric complications in patients with epilepsy: A review. Epilepsy
Res. 2002;49:11.
Oyebode F: The neurology of psychosis. Med Princ Pract. 2008;17:263.
Reuber M, Pukrop R, Bauer J, Helmstaedter C, Tessendorf N: Outcome in psychogenic
nonepileptic seizures: 1 to 10-year follow-up in 164 patients. Ann Neurol. 2003;53:305.
Riggio S: Psychiatric manifestations of nonconvulsive status epilepticus. Mt Sinai J Med.
2006;73:960.
Swinkels WAM, Kuyk J, van Dyck R, Spinhoven
Ph: Psychiatric comorbidity in epilepsy. Epilepsy
Behav. 2005;7:37.
Wong MT, Lumsden J, Fenton GW, Fenwick PB:
Electroencephalography, computed tomography
and violence ratings of male patients in a
maximum-security mental hospital. Acta
Psychiatr Scand. 1994;90:97.
Reference articles related IJP
•
Neuro-Psychological Profile Of Epilepsy On LuriaNebraska Neuropsychological Battery B.P.
Mishra, R. Mahajan, A. Dhanuka, R.L. Narang
Indian Journal of Psychiatry, Year 2002, Volume
44, Issue 1

24. •
•
•
•
•
•
Psychiatric Aspects of Epilepsy N.G. Chakraborty
Indian Journal of Psychiatry, Year 1966, Volume
8, Issue 3 IJP_psychiatric aspects of
epilepsy_chakravarthy.pdf
A Psycho-Social Study Of 180 Cases Of Epilepsy
V. N Bagadia, D. V Jeste, A. S Charegaonkar, P. V
Pradhan, L. P Shah Indian Journal of Psychiatry,
Year 1973, Volume 15, Issue 4
Reference articles related to pediatric epilepsy
Austin JK, Caplan R: Behavioral and psychiatric
comorbidities in pediatric epilepsy: Toward an
integrated model. Epilepsia. 2007:48:1639.
Caplan R, Siddarth P, Stahl L, Lanphier E, Vona P:
Childhood absence epilepsy: Behavioral,
cognitive, and linguistic comorbidities. Epilepsia.
2008 [Epub ahead of print].
Ott D, Siddarth P, Gurbani S, Koh S, Tournay A:
Behavioral disorders in pediatric epilepsy.
Epilepsia. 2003;44:591.
IJP article

25. •
Psychiatric Disorders In Children With Temporal
Lobe Epilepsy A Controlled Investigation G. D
Shukla, S. C Katiyar Indian Journal of Psychiatry,
Year 1981, Volume 23, Issue 1
Ictal Features
Ictal psychic symptoms
•
Seizure discharges can produce
–
–
semipurposeful automatisms
and psychic auras, such
• as mood changes,
• derealization and
• depersonalization,
• and forced thinking.
•
•
•
The experience of epileptic derealization or
depersonalization could impair realitytesting
Some patients have pleasurable auras
Another psychic aura is “forced thinking,”
characterized by recurrent intrusive thoughts,
ideas, or crowding of thoughts.

26. – Forced thinking must be distinguished from
obsessional thoughts and compulsive urges.
– Epileptic patients with forced thinking
experience their thoughts as stereotypical,
out-of-context, brief, and irrational, but not
necessarily as ego dystonic.
•
Recurrent or prolonged simple partial seizures
–
–
•
do not result in alteration of consciousness or
invariable abnormalities on EEG, and,
if manifested by psychic auras, simple partial
seizures may be difficult to distinguish from
primary psychiatric disturbances.
status epilepticus from complex partial seizures
and absence seizures results in
– prolonged alterations of responsiveness.
– With the addition of various ictal auras,
complex partial status epilepticus can appear
psychotic.

27. •
•
•
Ictal fear, which ranges from a vague
apprehension to abject fright, has occurred
without any other seizure manifestation,
and ictal depression has extended days or longer
after the seizure has passed.
Cognitive disorders follow status epilepticus
with simple partial seizures, complex partial
seizures, or absence seizures.
Peri-ictal features
Prodomal features
•
Some patients experience prodromal symptoms
– that begin at least 30 minutes before seizure
onset,
– last 10 minutes to 3 days,
– and are continuous with irritability,
depression, headache, confusion, and other
symptoms.
Peri ictal features
Postictal confusion

28. •
The postictal period is characterized by a
confusional state
– lasting minutes to hours or, occasionally,
days.
– Prolonged, postictal confusion may
particularly follow right temporal complex
partial seizures.
•
Some “twilight states” result from a protracted
period of intermixed ictal and postictal changes.
Peri-ictal features
Perictal psychosis
•
•
Concomitant with increased seizure frequency
Concomitant with decreased seizure frequency
•
•
postictal psychoses
Peri-ictal psychotic symptoms often worsen with
increasing seizure activity.

29. •
Rarely, psychotic symptoms alternate with
seizure activity. In this alternating psychosis,
–
–
but when they are seizure free and their EEG has
forced or paradoxical normalization, they
manifest psychotic symptoms.
–
•
when patients are having seizures, they are free
of psychotic symptoms,
This alternating pattern is much less common
than the increased emergence of psychotic
behavior with increasing seizure activity.
An important peri-ictal psychiatric disorder
consists of
–
•
brief psychotic episodes that follow clusters of
generalized tonic-clonic seizures (i.e., postictal
psychosis).
These psychotic episodes occur in patients who
have
–
–
complex partial seizures,
–
bilateral interictal discharges,
frequent secondary generalization to tonic-clonic
seizures,

30. –
•
•
The postictal psychosis of epilepsy emerges after
a lucid interval of 2 to 72 hours (with a mean of
1 day), during which the immediate postictal
confusion resolves, and the patient appears to
return to normal
The postictal psychotic episodes last 16 to 432
hours (with a mean of 3.5 days) and often
include
–
–
–
–
•
•
and frequent discharges involving the left
amygdala.
grandiose or religious delusions,
elevated moods or sudden mood swings,
agitation, paranoia, and impulsive behaviors,
but no perceptual delusions or voices are heard.
The postictal psychoses remit spontaneously or
with the use of low-dose psychotropic
medication.
Reference articles

31. •
Kanemoto K, Kawasaki J, Kawai I: Postictal
psychosis: A comparison with acute interictal
and chronic psychoses. Epilepsia. 1996;37:551.
Interictal feature schizophreniform
psychosis
Psychosis in general
•
•
•
•
is the specific psychiatric disorder most clearly
associated with epilepsy.
The lifelong prevalence of all psychotic disorders
among epileptic patients ranges from 7 to 12
percent
patients whose epilepsy has a mediobasal
temporal focus are especially at risk.
Studies on the laterality of the seizure focus
suggest an association of a left-sided focus with
psychosis.
•
•
Most epilepsy patients with a schizophreniform
psychosis have

32. – a chronic interictal illness
– without a known direct relationship to
seizure events or ictal discharges.
•
Many of these patients, however, develop
worsening psychotic symptoms that are
concomitant with
–
–
–
•
an increase in seizure frequency or
with antiepileptic drug withdrawal, and
a few others have worsening psychotic symptoms
on control of the seizures (alternating psychosis).
Epilepsy patients with this chronic interictal psychosis
–
–
often have an early age of onset of seizures and
a decade or more of poorly controlled partial complex
seizures, usually with secondary generalized tonic-clonic
seizures.
•
This interictal psychosis may evolve from prior
recurrent postictal psychotic episodes.
•
Seizure control with antiepileptic drugs or removal of
the seizure focus does not prevent the development
of the interictal psychosis, which occasionally
emerges for the first time after successful seizure
treatment.

33. •
•
This disorder sometimes resembles a
schizoaffective psychosis with intermixed
affective symptoms.
In addition, there are
–
–
–
–
•
•
•
•
•
•
prominent paranoid delusions,
relative preserved affect,
normal premorbid personality,
and no family history of schizophrenia
Complex partial seizures with secondary
generalized tonic-clonic seizures
More auras and automatisms than
nonpsychotic epilepsy patients
Epilepsy present for 11 to 15 years before
psychosis
Long interval of poorly controlled seizures
Recently diminished seizure frequency,
especially generalized tonic-clonic seizures
Left temporal focus

34. •
•
•
•
•
•
•
•
•
•
•
•
Mediobasal temporal lesions, especially
tumors
Atypical paranoid psychosis–paranoia with
sudden onset
Psychosis alternating with seizures
Preserved affective warmth
Failure of personality deterioration
Less social withdrawal than schizophrenia
Less systematized delusions than schizophrenia
More hallucinations and affective symptoms
than schizophrenia
More religiosity than schizophrenia
More positive, as opposed to negative,
symptoms
Few schneiderian first-rank symptoms
Reference articles related to psychosis

35. •
•
Slater E, Beard A: The schizophrenialike
psychosis of epilepsy: Psychiatric aspects. Br J
Psychiatry. 1963;109:95.
Sachdev P. Schizophrenia-like psychosis and
epilepsy: The status of the association. Am J
Psychiatry. 1998;155:325.
•
Tarulli A, Devinsky O, Alper K: Progression of
postictal to interictal psychosis. Epilepsia.
2001;42:1468.
IJP article
•
Psychosis In Relation To Epilepsy - A Clinical
Model Of Neuro – Psychiatry Indian Journal of
Psychiatry, Year 1996, Volume 38, Issue 3
Interictal features
Personality Disorders
•
Among epileptic patients, there is a high
prevalence of personality disorders, including

36. –
–
–
–
•
•
and dependent disorders.
dependent and avoidant personality traits.
Not surprisingly, epileptic patients frequently
lack a stable character structure and
can be immature and impulsive
This personality constellation partially explains
the increased incidence of
–
–
–
•
histrionic,
The most common personality disorder in
epilepsy is a borderline personality.
–
–
•
atypical or mixed,
Patients with personality disorders tend to show
–
•
borderline,
irritability,
suicide attempts,
and intermittent explosive disorder.
Those with epilepsy are
–
stigmatized,

37. –
–
–
–
•
•
and subject to difficulties in obtaining a job,
driving an automobile,
and maintaining a marriage.
These psychosocial difficulties, along with any
associated mental retardation, contribute to
–
–
–
•
feared,
the dependency,
low self-esteem,
and overall borderline personality traits present in
many such patients.
In addition, the experience of epileptic auras
may contribute to the development of
personality disorders.
Studies with the Bear-Fedio Inventory, an MMPIlike instrument developed to assess these
“epileptic traits,” found that epileptic patients
with temporal lobe foci were
–
–
sober and humorless,
dependent, and

38. –
–
•
had strong philosophical interests
In addition, those with a left-sided focus had a
more reflective ideational style and maximized
their problems,
–
•
circumstantial and
whereas those with a right-sided focus had
emotional tendencies and minimized their
problems.
Further investigations with the Bear-Fedio
Inventory described these seizure patients as
– having viscosity in interactions,
– prominent religious interests,
– a pronounced sense of personal destiny,
– and deepened affect.
•
•
Reference articles related to personality changes
Swanson SJ, Rao SM, Grafman J, Salazar AM,
Kraft J: The relationship between seizure subtype
and interictal personality. Results from the
Vietnam Head Injury Study. Brain. 1995;118:91

39. IJP article
•
Religious Conversion In Temporal Lobe Epilepsy
G.D Shukla, B.C Katiyar, O.N Srivastava Indian
Journal of Psychiatry, Year 1978, Volume 20,
Issue 4
Interictal feature
Gastaut-Geschwind Syndromes
•
•
•
Although there is no general epileptic
personality, a group of traits termed the
Gastaut-Geschwind syndrome occurs in a subset
of patients with complex partial seizures.
Some epilepsy patients with a temporal limbic
focus develop a sense of the heightened
significance of things.
These patients are serious, humorless, and
overinclusive and have an intense interest in
philosophical, moral, or religious issues

40. •
•
Occasionally, epilepsy patients experience
multiple religious conversions or experiences.
In interpersonal encounters, they demonstrate
viscosity, the tendency to talk repetitively and
circumstantially about a restricted range of
topics
–
•
Viscosity may particularly occur in patients with
left-sided or bilateral temporal foci.
They can spend a long time getting to the point,
give detailed background information with
multiple quotations, or write copiously about
their thoughts and feelings (hypergraphia).
Behavioral Disturbances Variably Related to
Ictus
Mood Disorders
• Depression

41. •
•
•
•
•
•
Depressive disorder is the most prevalent
neuropsychiatric disorder in epilepsy, occurring
in 7.5 to 25 percent of epileptic patients.
Depression is also the main diagnosis among
epileptic patients in mental hospitals.
Depression is twice as common in epilepsy
patients as in comparably disabled populations,
suggesting that much of the depression in
epilepsy patients is more than just a
psychological reaction to a disability.
Patients with interictal dysphoria tend to have
frequent complex partial seizures, possibly with
greater left-sided temporal foci, although this
lateralization is not established.
The experience of certain psychic auras,
especially those with cognitive content, may
predispose to interictal depression.
These patients may have accompanying paranoia
and hallucinations, emphasizing the continuum
with psychotic disorders.

42. •
•
•
•
•
•
Several investigators also report increased
seizure control or a decrease in seizures before
the onset of interictal depressive symptoms.
Patients with this “alternating depression”
experience relief with a seizure or
electroconvulsive therapy (ECT).
The rare occurrence of ictal depression may not
only outlast the actual ictus but also may lead to
suicide.
Depression also occurs peri-ictally.
Postictal depression is common, and a
prolonged depressive state occasionally follows
complex partial seizures, even when ictal
experiences do not include depression.
Episodic mood disturbances, often with
agitation, suicidal behavior, and psychotic
symptoms, may occur with increasing seizure
activity.

43. •
•
•
•
•
•
•
•
•
•
Mania
Mood disorder due to epilepsy with manic
features or with mixed features is much rarer
than mood disorder due to epilepsy with
depressive features or with major depressivelike
features.
Although a right temporal focus is a possible
source of mania in epilepsy, this laterality is not
established.
Reference articles related to affective disorders
Baker GA: Depression and suicide in adolescents with epilepsy. Neurology. 2006;66:S5.
Blumer D, Montouris G, Davies K: The interictal dysphoric disorder: recognition,
pathogenesis, and treatment of the major psychiatric disorder of epilepsy. Epilepsy Behav.
2004;5:826.
Ekinci O, Titus JB, Rodopman AA, Berkem M, Trevathan E: Depression and anxiety in
children and adolescents with epilepsy: Prevalence, risk factors, and treatment. Epilepsy
Behav. 2008 [Epub ahead of print].
Fuller–Thomson E, Brennenstuhl S: The association between depression and epilepsy in a
nationally representative sample. Epilepsia. 2008 [Epub ahead of print].
Jackson MJ, Turkington D: Depression and anxiety in epilepsy. J Neurol Neurosurg
Psychiatry. 2005;76:i45.

44. •
•
•
•
Paradiso S, Hermann BP, Blumer D, Davies K,
Robinson RG: Impact of depressed mood on
neuropsychological status in temporal lobe
epilepsy. J Neurol Neurosurg Psychiatry.
2001;70:180.
Seethalakshmi R, Krishnamoorthy ES:
Depression in epilepsy: Phenomenology,
diagnosis and management. Epileptic Disord.
2007;9:1
Barry JJ, Ettinger AB, Friel P, Gilliam FG,
Harden CL: Advisory Group of the Epilepsy
Foundation as part of its Mood Disorder:
Consensus statement: the evaluation and
treatment of people with epilepsy and
affective disorders. Epilepsy Behav. 2008;13
Suppl 1:S1.
Williams D: The structure of emotions
reflected in epileptic experiences. Brain.
1956;79:29.
IJP articles

45. •
•
A Study To Assess Depression, Its Correlates
And Suicidal Behaviour In Epilepsy; Rajesh
Jacob, M. Suresh Kumar, R. Rajkumar, V.
Palaniappun Indian Journal of Psychiatry,
Year 2002, Volume 44, Issue 2ORIGINAL
ARTICLE: High prevalence of depression
among Iranian patients with first onset
pseudoseizures
Alireza Farnam, Mohammad Ali
Goreishizadeh, Sara Farhang, Fatemeh
Abdolaliyan Indian Journal of Psychiatry,
Year 2008, Volume 50, Issue 4
Behavioral Disturbances Variably Related to Ictus
Anxiety Disorders
•
•
Anxiety and panic disorders occur among
epileptic patients and must be distinguished
from simple partial seizures manifesting as
anxiety or panic.
Anxiety may be present with depression or
other psychopathology, as part of Cluster C

46. personality disorders, or independently as a
generalized anxiety disorder.
•
•
•
Some patients with epilepsy clearly have
posttraumatic stress disorder (PTSD) from the
psychological trauma of their recurrent seizures.
This may contribute to the prevalence of
nonepileptic seizure epilepsy among patients
with true epilepsy.
Finally, among the impulse control disorders,
intermittent explosive disorder is characterized
by a prodromal of anxiety with increasing
tension and irritability.
Behavioral Disturbances Variably Related to Ictus
Aggression
•
although the prevalence of epilepsy among
prison inmates has been two to four times that
among the general population, studies from the

47. United Kingdom and the United States have not
found more violent crimes among prisoners with
epilepsy than among prisoners without epilepsy.
•
•
•
•
high violence rating scores are associated with
abnormal temporal electrical discharges on EEG
and temporal lobe abnormalities on CT.
Moreover, patients with left temporal lobe
seizure foci have higher scores on hostile
feelings than other patients with epilepsy.
Although aggression can occur in relation to an
ictus, most aggression among epilepsy patients
is not related to epileptiform activity.
Aggression in epilepsy is usually associated with
psychosis or with intermittent explosive
disorder and correlates with
– subnormal intelligence,
– lower socioeconomic status (SES),

48. – childhood behavior problems,
– prior head injuries, and
– possible orbital frontal damage.
•
•
•
Simple violent automatisms, such as spitting or
flailing the arms, can occur at the onset of
complex partial seizures,
and secondary violent automatisms can occur as
a response to an unpleasant or emotional aura
or peri-ictal sensation
More commonly, nondirected violent
movements, aimless destructive behavior, or
angry verbal outbursts
–
–
•
occur during postictal delirium when patients
misinterpret attempts to protect or restrain them
or
as a manifestation of postictal psychosis and
subacute postictal aggression.
The diagnosis of epilepsy is established by at least one specialist in
epilepsy.

49. •
The presence of epileptic automatisms are documented by history
and by closed circuit television EEG telemetry.
•
The presence of violence during epileptic automatisms is verified in
a videotape-recorded seizure in which ictal epileptiform patterns
are also recorded on the EEG.
•
The aggressive act is characteristic of the patient's habitual
seizures, as elicited by history.
•
A clinical judgment is made by the epilepsy specialist attesting to
the possibility that the aggressive act was part of a seizure.
•
EEG, electroencephalogram.
•
Reference article related aggression
IJP article
•
Crimes Of Persons With Epilepsy O
Somasundaram Indian Journal of Psychiatry, Year
1972, Volume 14, Issue 4
Behavioral Disturbances Variably Related to Ictus
sexuality
•
•
Patients with epilepsy tend to be hyposexual
Men have an increased risk of erectile dysfunction, suggesting a
neurophysiological component,
–
•
and studies of sex hormones suggest the possibility of a
subclinical hypogonadotropic hypogonadism
True ictal sexual manifestations are also unusual;

50. –
–
•
•
however, libidinous feelings, erotic sensations, sexual
remembrances, and even orgasm rarely occur, primarily in
women and probably from seizure discharges in the amygdala.
In addition, ictal masturbation has occurred with absence
status.
Reference articles related to sexuality
Morrell MJ, Guldner GT: Self-reported sexual
function and sexual arousability in women with
epilepsy. Epilepsia. 1996;37:1204.
IJP article
•
Temporal Lobe Epilepsy : Phenomenology And
Psycho-Sexul Manifestations G. D Shukla Indian
Journal of Psychiatry, Year 1984, Volume 26,
Issue 1
Behavioral Disturbances Variably Related to Ictus
Suicide
•
The risk of completed suicide in epilepsy patients is
four to five times greater than that among the
nonepileptic population,
•
and those with complex partial seizures of temporal
lobe origin have a particularly high risk, as much as 25
times greater.

51. •
Death by suicide occurs in 3 to 7 percent of epilepsy
patients
•
This increased risk of suicide continues even long
after temporal lobectomy and successful control of
seizures.
•
•
•
Most suicidal behavior among epileptic patients
is not directly due to reactions to the
psychosocial stressors of having a seizure
disorder.
Rather, these patients are likely to attempt
suicide in conjunction with borderline
personality behaviors and are likely to complete
suicide during postictal psychosis.
Contributors to successful suicides include
–
–
–
•
paranoid hallucinations,
agitated compunction to kill themselves,
and occasional ictal command hallucinations to
commit suicide.
Reference articles related to suicide

52. •
Jones JE, Hermann BP, Gilliam FG, Kanner AM,
Meader KJ: Rates and risk factors for suicide,
suicidal ideation, and suicide attempts in chronic
epilepsy. Epilepsy Behav. 2003;4:S31
IJP article
•
CME: Self-injurious behavior: A clinical appraisal
K Nagaraja Rao, CY Sudarshan, Shamshad Begum
Indian Journal of Psychiatry, Year 2008, Volume
50, Issue 4
Behavioral Disturbances Variably Related to Ictus
Other behavioral changes
•
A specific association of epilepsy with
–
–
–
–
–
dissociative identity disorder,
depersonalization disorders,
possession states,
fugue states, and
psychogenic amnesia
• is intriguing but unresolved.

53. •
•
•
In epilepsy, prolonged periods of compulsive
wandering with amnesia have resulted from an
admixture of ictal and postictal changes and
have been termed poriomania.
Among the somatoform disorders, some
epileptic patients have a conversion disorder,
often manifested as nonepileptic seizure events.
Finally, patients with epilepsy are subject to
other behavioral difficulties stemming from their
epilepsy, such as
–
–
–
adjustment disorders,
subtle cognitive effects of seizures, and
the potential behavioral effects of antiepileptic
medications.
Management implications

54. •
•
In treating the neuropsychiatric disorders of
epilepsy, a final consideration is altering the
seizure management itself.
In addition to the occasional behavior alleviated
by strict seizure control,
– allowing seizures under carefully controlled
conditions, much like ECT, may relieve some
cases of peri-ictal psychosis, depression, or
other behaviors.
•
Psychiatrists and neurologists need to
–
–
consider the seizure threshold lowering effects of
some psychotropic medications,
–
•
maximize the mood stabilizing and other
psychotropic effects of antiepileptic drugs,
and monitor the potential interaction of
antiepileptic and psychotropic drugs.
Antiepileptic Medications

55. •
•
In the treatment of psychiatrically disturbed
epileptic patients, a first consideration is the
behavioral effects of antiepileptic medications.
Carbamazepine, valproate, lamotrigine, and
gabapentink (Neurontin) have significant
antimanic and modest antidepressant
properties, probably through mood stabilization
effects.
–
•
•
•
•
They have some efficacy in the long-term
prophylaxis of manic and depressive episodes.
Carbamazepine and valproate may also
ameliorate some dyscontrolled, aggressive
behavior in brain-injured patients.
Clonazepam, in addition to its anxiolytic
properties, can serve as a supplement to other
antimanic therapies.
Gabapentin also decreases anxiety and improves
general well-being in some epilepsy patients.
Carbamazepine and ethosuximide may have
value for borderline personality disorder.

56. •
•
•
•
•
•
Encephalopathic changes occur at toxic levels of
all antiepileptic drugs.
Even at therapeutic levels, barbiturates may
need discontinuation because of drug-induced
depression, suicidal ideation, sedation,
psychomotor slowing, and paradoxical
hyperactivity in the very young and the very old.
Gabapentin may induce aggressive behavior or
hypomania,
and vigabatrin (Sabril) may precipitate
depression.
In addition, clinicians need to be aware of the
potential emergence of psychopathology on
withdrawal of antiepileptic medications.
Anxiety and depression are the most common
emergent symptoms, but psychosis and other
behaviors may also occur.

57. •
•
•
•
•
•
•
•
•
•
•
•
•
•
Seizure Threshold Lowering Effect of
Psychotropic Medications-- high
Antipsychotic
Chlorpromazine (Thorazine
Clozapine (Clozaril)
Antidepressant
Bupropion (Wellbutrin)
Imipramine (Norfranil)
Maprotiline (Ludiomil)
Amitriptyline (Elavil)
Amoxapine (Asendin)
Nortriptyline (Aventyl)
Seizure Threshold Lowering Effect of
Psychotropic Medications– Moderate
antipsychotics
Most piperazines

58. •
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Thiothixene (Navane)
antidepressants
Protriptyline (Vivactil)
Clomipramine (Anafranil)
Other drugs
Lithium (Eskalith)
Seizure Threshold Lowering Effect of
Psychotropic Medications– Low
Antipsychotics
Fluphenazine (Prolixin)
Haloperidol (Haldol)
Loxapine (Loxitane)
Molindone (Moban)
Pimozide (Orap)
Thioridazine (Mellaril)
Risperidone (Risperdal)

59. •
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Olanzapine (Zyprexa)
Ziprasidone (Geodon)
Aripiprazole (Abilify)
Antidepressants
Doxepin (Sinequan)
Desipramine (Norpramin)
Trazodone (Desyrel)
Trimipramine (Surmontil)
Selective serotonin reuptake inhibitors
Other psychotropics
Ethchlorvynol (Placidol)
Glutethimide (Doriden)
Hydroxyzine (Vistaril)
Meprobamate (Equanil)
Methaqualone (Quaalude)

60. •
•
•
•
Psychotropic medications
A second consideration is the seizure threshold
lowering effect of psychotropic medications.
This is usually not a problem but can occasionally
reach clinical significance in poorly controlled
epilepsy.
Psychotropic drugs are most convulsive with
rapid introduction of the drug and in high doses.
–
•
•
•
Clozapine (Clozaril), for example, has induced
seizures in 1.0 to 4.4 percent of patients,
particularly when the dose was rapidly increased.
When initiating psychotropic therapy, it is best
to start low and go slow while monitoring
antiepileptic levels and EEGs.
Drug Interactions
A third treatment consideration is the potential
for interaction of antiepileptic and psychotropic
medications.

61. •
•
•
•
Most commonly, an antiepileptic drug increases
the metabolism of a psychotropic drug with a
consequent decrease in its therapeutic
efficiency.
Conversely, withdrawal of antiepileptic drugs can
precipitate rebound elevations in psychotropic
levels.
Moreover, the initiation of a psychotropic drug
may result in competitive inhibition of
antiepileptic drug metabolism with elevations of
antiepileptic drug levels to toxicity.
In comparison to older drugs, the new
antiepileptic medications have fewer potential
interactions with psychotropic medications.
–
•
Gabapentin, lamotrigine, vigabatrin, and tiagabine
(Gabitril) are relatively free of enzyme-inducing or
-inhibiting properties.
Antiepileptic-Psychotropic Drug Effects on Blood
Levels

62. •
•
Reference articles related to pharmacotherapy
Ettinger AB: Psychotropic effects of antiepileptic
drugs. Neurology. 2006;67:1916.
•
Schmitz B: Effects of antiepileptic drugs on mood
and behavior. Epilepsia. 2006;47(Suppl 2):28.
IJP article
•
•
•
•
CASE REPORT: Valproic acid-induced abnormal
behavior Nanjangud Chandrashekar
Nagalakshmi, Madhan Ramesh, Gurumurthy
Parthasarathi, Anand Harugeri, Mary Sam
Christy, Belur Seshachala Keshava Indian Journal
of Psychiatry, Year 2010, Volume 52, Issue 1
Neurosurgical aspects
Epilepsy surgery is a fourth treatment consideration and is limited
to patients with medically intractable seizures.
The main operation involves resection of epileptogenic tissue by
removal of 4 to 6 cm of the anterior temporal lobe.
–
–
More than 80 percent of temporal lobectomy patients experience some reduction
in their seizure frequency, and more than 50 percent of patients are entirely seizure
free.
Removal of the amygdala and most of the hippocampus may have postoperative
behavioral effects
.

63. –
–
and patients occasionally develop a transient
postoperative affective disorder.
–
Others experience a reduction in postictal
psychosis, depression, and hyposexuality,
–
but epileptic patients may continue to develop
interictal psychosis, personality changes, and
suicidal behavior even long after the temporal
lobectomy.
–
•
Some patients have an anomia or a verbal
memory deficit after resection of the dominant
hemisphere,
Moreover, patients with preoperative psychotic
symptoms are at higher risk for a poor surgical
outcome and postoperative psychosis.
Less common epilepsy surgeries include
–
–
–
•
resection of extratemporal lesions,
removal of the epileptogenic hemisphere,
and ligation of the corpus callosum.
Corpus callosotomy,

64. –
which aims to prevent the interhemispheric
spread of seizures,
–
results in a unique, transient disconnection
syndrome of mutism, apathy, agnosia, apraxia of
the nondominant limbs, difficulty naming, and
writing with the nondominant hand.
References
CTP 9TH ED
SOP 10TH
•
•
•
Further reading
Ettinger AB, Kanner AM: Psychiatric Issues in
Epilepsy: A Practical Guide to Diagnosis and
Treatment. New York: Lippincott Williams &
Wilkins; 2006.
*Schachter SC, Holmes GL, Kasteleijn-Nolst
Trenite DGA, eds. Behavioral Aspects of Epilepsy:
Principles and Practice. New York: Demos
Medical Publishing; 2008.