The document provides an overview of the relationship between epilepsy and behavioral disorders, highlighting the prevalence of psychiatric issues in patients with epilepsy. It discusses the challenges in classifying these disorders, the impact of anti-epileptic drugs, and the different types of psychoses associated with epilepsy. Furthermore, it emphasizes the need for better population-based studies and the consideration of personalized treatment approaches for managing co-morbid conditions.

1. Epilepsy and Behaviour
- An Overview
Dr. Ennapadam.S. Krishnamoorthy
MD., DCN, PhD (Lond), FRCP (Lond, Glas, Edin), MAMS (India)
Founder Director
TRIMED I NEUROKRISH
www.trimedtherapy.com I www.neurokrish.com

2. Epilepsy and Behaviour
“Epilepsy and mental disorder are two states of
illness of the very closest relationship; they
represent identical pathological conditions in two
different areas of the nervous system”
Carl-Friedrich Flemming (1799-1880)
Director of ‘Sachsenberg’

3. Epidemiology of psychiatric disorders in
epilepsy
• Most studies hospital or institution based
• Few population based studies
• Most studies cross-sectional
• More recently cohort studies and nested case-control
studies reported
• Estimates of prevalence available but not other
epidemiological indices

4. Large hospital based studies
• 1971: Currie et al; 49% of 666 patients
• 1991: Guruje; 37% of 204 patients
• 1993: Mendez et al;Schizophrenia in 9.25%
(epilepsy) vs.. 1.06% (migraine)
• 1996: Manchanda et al; 47.3% of 300 patients met
DSM-III-R criteria

5. Meta-analysis
• Whitman (1984); Dodrill (1986)
Patients with epilepsy
- higher risk of psychopathology than normal controls
- similar to patients with chronic illness
- no differences between TLE and generalised
epilepsy

6. Population Based Studies
• 1960: Pond and Bidwell; 29% of 245 patients had
psychological disorders
• 1966: Gudmundsson; 512 (52%) of 987 patients
showed mental changes
• 1987: Edeh and Toone; 47.7% of 88 patients
emerged as psychiatric cases
• 1996: Cockerell et al; 64 incident cases/ 1 year
with acute psychological disorders

7. Population based studies
• Jalava (1996); 35 year cohort study - 4 fold risk of
behavioural disorder epilepsy
• Bredkjaer (1998); Record linkage- epilepsy and
psychiatry registers; SIR-schizophreniform psychosis
(p<10-8)
• Stefansson (1998): disability register based case-control-
epilepsy and somatic illness: no difference

8. Classification And Diagnosis Of
Psychiatric Disorders In Epilepsy

9. Classification- current status
• Both ILAE & WHO classifications of epilepsy do not
code psychiatric disorders
• Both ICD-10 & DSM-IV- “epilepsy” automatically
subsumed under “organic” diagnosis category
• Existing descriptions in these classifications often
not comparable with psychiatric disorders specific to
epilepsy

10. Ideal classification
• Distinguish epilepsy specific psychiatric disorder
from common mental disorder
• Link with the ILAE classification of epilepsy
• Code other data of relevance such as EEG and AED
therapy
• ILAE Commission on Psychobiology is working
towards developing this

11. I. The problem of co-morbidity
• Co-morbid behavioural disorders like anxiety and
depression are common in epilepsy as in other
chronic illnesses
• Do not have specific distinguishing features that
separate them from those seen in the community
• Suggestion: Diagnose using ICD-10 and DSM-IV
criteria; ignore “organic” label

12. II. Seizures as psychopathology
• Clinical and sub-clinical seizure activity have
psychiatric manifestations
• Correlate clinical state with EEG for diagnosis
- Complex partial status (impaired awareness)
- Simple partial status (aura continua)
- Absence status (spike-wave stupor)

13. III. Psychiatric disorders specific to
epilepsy

14. Cognitive Dysfunction
Due to epilepsy, its complications or due to anti-epileptic
drugs
General or specific difficulties with
• memory
• language
• visuo-spatial ability
• sensorimotor and perceptual functions

15. Management of Cognitive Dysfunction
• Consider role of AED’s either singly or in
combination
• Newer AED’s like Topiramate cause considerable
cognitive change
• optimise prescription of drugs
• Rule out sub-clinical status
• Rule out metabolic/infectious cause

16. Case Vignette
• Male/ 40’s/ refractory TLE
• Admitted for investigation and treatment
• Rapidly progressive cognitive decline after
admission- dementia screen negative
• Acute behavioural disturbance
• High ammonia level and characteristic EEG change-
“Valproate Encephalopathy”
• reversed with Valproate withdrawal

17. Psychoses of epilepsy
• Inter-ictal psychosis- unrelated to/ unaffected by
seizures; schizophrenia like
• Alternative psychosis- occurs during periods of
seizure freedom with forced normalization of EEG
• Post-ictal psychosis- follows cluster/ rarely single
seizure; lucid interval of 24-48 hrs; lasts for as long
as a month

18. Psychoses of epilepsy- features
• preserved personality
• warm affect
• significant component of mood change
• paranoid and religious themes
• polymorphic in nature
• often subtle

19. Management of Psychoses
• Rule out metabolic or infectious causes/ sub-clinical
status
• Post-ictal- prevent seizures; indication for surgery;
use Clobazam/ antipsychotics
• Inter-ictal- new antipsychotic drugs (treatment and
prophylaxis)
• Alternate- complete seizure freedom is not always
an ideal to aspire for

20. Depression in epilepsy
Symptoms: irritability, depressive moods,
anergia, insomnia, atypical pains, anxiety, phobic
fears and euphoric moods (3 of 8)
• Interictal dysphoric disorder- unrelated to/
largely unaffected by seizures
• Prodromal dysphoric disorder- indicates the
impending onset of seizures
• Postictal dysphoric disorder-follows seizure

21. Management of Depression
• Link with menstrual periods in women
• Role of AED’s
• SSRI’s can be used to prevent episodes
• Post-ictal dysphoria: control of seizures; consider
using Clobazam as prophylactic
• Counselling (sharing information)
• Cognitive Behavioural Therapy/ Psychotherapy

22. Case Vignette
• 32/male/frontal lobe seizures
• Topiramate- complete seizure freedom
• developed Abulia without mood or psychotic
symptoms
• Newer antidepressant and Viagra prescribed by GP
• Seizures returned- behaviour normalised

23. Geschwind Syndrome
Inter-ictal syndrome characterised by
• intensified and labile emotionality
• viscosity (orderliness, excessive attention to detail
and persistence)
• hyposexuality
• religiosity
• hypergraphia

24. Sensory- Limbic
Hyper-connection
increased electrical activity-temporal lobe

enhanced connection between sensory input and
limbic processing

sensory experience suffused with emotional
coloration

25. Geschwind Syndrome
and Laterality
RIGHT SIDED FOCUS
(EMOTIVE)
emotionality
elation and sadness
Tendency to ‘polish’
image
LEFT SIDED FOCUS
(IDEATIVE)
sense of personal destiny
philosophical interests
Tendency to ‘tarnish’ image

26. Geschwind versus Kluver-Bucy
HYPERCONNECTION
EMOTIONAL INTENSITY
VISCOSITY
HYPOSEXUALITY
DISCONNECTION
PLACIDITY
HYPERMETAMOR-PHOSIS
HYPERSEXUALITY

27. Management of
Geschwind Syndrome
• Often positive attributes- meticulous, religious,
moral people with high integrity
• When personality traits cause impairment
- consider prophylactic antidepressant in people with
inter-ictal dysphoria
- consider prophylactic newer antipsychotic for those
with subtle psychotic features, irritability or
aggression

28. The Future
• Well designed population based studies using
epilepsy specific measures
• Role of seizures, EEG and anti-epileptic drugs need
to be explored
• Need for formal therapeutic trials in epilepsy specific
behaviour disorder
• Explore biological link between epilepsy and
behaviour

29. Selected Reading
• M.R.Trimble. The Psychoses of Epilepsy, 1992,
Raven Press, New York.
• Krishnamoorthy & Trimble. (Forced
Normalization); Lambert & Robertson.
(Depression); both in
Epilepsia 1999; vol.40 (suppl. 10)
• D.Blumer & O.Devinsky- Evidence for and against
temporal lobe syndrome. Neurology 1999; vol.53
(suppl. 2)

30. Thank You
email: research@neurokrish.com