The link between epilepsy and psychiatry

– What is epilepsy, which shared area of disciplines does it come under?
Before we define epilepsy we have to define seizures. A seizure is a spontaneous sudden discharge of the brain cells (neurons). In order to be called epilepsy the patient has to have had at least one such seizure and carry the risk of having others. Epilepsy comes mainly within the field of psychiatry and neurology.

– What is the psychiatric aspect of epilepsy? Can you go into details.

Before, during and after an epileptic seizure and between seizures we encounter almost all forms of psychiatric phenomena. Since in epilepsy the probability of encountering a psychiatric picture is over 50%, we could safely say that epileptology without psychiatry in unthinkable.

– I believe it has more aspects in common with neurology. What are these aspects?
There are many types of epilepsy. These can start at different locations in the brain. They may remain limited to that area of the brain or spread to the whole of the brain. Traumas, infections, tumours, developmental faults in the finer brain structure can all create a neurological base for epilepsy and trigger it. In other words, epilepsy is entirely a disease of the brain. We can therefore say that epileptology without neurology will only be a dogma.

– Do psychiatric complaints in epilepsic patients vary from those in the normal population?
The occurrence rate of epilepsy in the entire population is around 1%. 50% of these have psychiatric symptoms. This means, that in epileptics the likelihood of psychiatric complaints is abnormally high in comparison to the normal population. Lets take depression for example. In epileptics the occurrence rate is in the region of 30%, whereas in the normal population it is around 4-5%.

– Can you define the word psychopathology in this context?
Epilepsy provides important evidence that psychopathology is a process that originates entirely from the brain.

– What changes take place in the brain during an epileptic seizure? Would you draw us a picture?
During epileptic seizures the brain undergoes changes in its bioelectrical activity . It is possible to monitor these changes with the help of EEG recordings. Particularly EEG recordings with video telemetry are like gold standards. EEG findings show that the changes which occur in the brain, differ according to the type of seizure. During a seizure anatomical, pathological, endocrinological and similar changes take place in the brain.

– What is the role and value of electrophysiology in diagnosing epilepsy?
Without the support of electrophysiology we cannot even talk about epilepsy. However, in some forms of epilepsy no EEG changes are recorded, and in others no epileptic phenomena are seen although the EEG shows epileptic discharges. This shows that serious expertise is required for electrophysiology in epilepsy.

– Within the field of psychiatry, what is the role of seizures in epilepsy and what are its reasons ?
As far as causing a psychiatric disorder is concerned, we are mainly talking about temporal epilepsy. However, epileptic discharge in any part can lead to a psychiatric symptom. The connection between temporal epilepsy and psychiatry can be explained as follows: the temporal area of the brain is located in the limbic system and plays a role in the control of emotions and thoughts. Therefore it is normal that any neural pathology in this area has psychiatric implications.

– Is epilepsy connected to depression?
As mentioned above, epilepsy and depression frequently occur together. Epilepsy can cause depression and depression can lead to epilepsy. There are signs that depression in epilepsy is caused by an interaction of the inhibitor neural mechanisms in between seizures. There are also a series of biological, psychological and social factors that increase the risk of depression in epileptics.

– Is there a similar connection to the manic depressive disorder?
Manic attacks connected to epilepsy are rare. More often a manic attack sets in when a depression turns into a bipolar state. This is more commonly seen in epilepsy that starts in childhood.

– Do we see personality disorders in epileptic patients?
Amongst epileptic people there is an increased likelihood of coming across individuals who place great importance on details, have difficulty in abstract thinking, are involved in extreme religious undertakings, and are less active sexually. In recent years the epileptic personality as it was thought of in the past, is again being discussed. Although it is difficult to draw up a typical profile, we really do witness the above mentioned characteristics more frequently in epileptic patients.

– Can epilepsy lead to personality disorders?
During recent years this approach is regarded as being without foundation.

– Which other psychiatric disorders are seen in epileptic people?
Almost all types of psychiatric disorders can be encountered, particularly depression. Also anxiety disorders, psychosis, attention deficit in children, hyperactivity and similar.

– To what extent do epileptic patients suffer from a feeling that at any moment something bad could happen. How does this affect their quality of life?
Generalized anxiety disorder is often seen amongst epileptics. They suffer from related anxiety. One of the reasons for this is that the seizures occur suddenly. And of course, what we call apprehension does greatly affect the quality of their life.

– What factors cause the greatest difficulties for epileptics?
Stigmatization. Sudden onset of seizures. Psychiatric disorders accompanying the illness. Social and economic difficulties. Inability to find employment or a spouse. The list is endless. It is therefore of great value if we all try and give our social support to epileptic individuals.

– What level of social involvement do we see in epileptics? How do the attacks or other symptoms of the illness affect their social relationships, do they weaken them?
Epileptics suffer serious problems in their social interrelationships. For example, it is known that only 8% of epileptics who resist treatment, find a spouse.

– What kind of a connection is there between epilepsy, the patient’s personality and the developmental level of the geographical region where the patient lives.

The lower the economic level, the more likely it is for depression to accompany epilepsy.

– What role does age play?
Epilepsy can be seen in individuals of any age. But the likelihood of it occurring in children and the elderly is higher. The risk of a psychiatric picture is not related to gender, it is the same for males and females.

– Are epileptic patients always in the same emotional state or does their emotional state vary?
As epilepsy is characterised by changes in the bioelectrical activity of the brain, and as emotions are a function of the brain, we can expect epileptics to show emotional variation. In fact, studies show that this inference is correct.

– Do people with epilepsy continue to learn?
Epilepsy, and particularly epilepsy that starts in childhood, has a negative effect on cognitive functions, and can lead to learning difficulties. For this reason such children have to be urgently placed under treatment.

– At what level is their speech ability?
During epileptic seizures we see some speech defects, stuttering etc. During the periods between seizures they experience difficulties in using language, abstracting, learning new words, and similar.

– What functions are epileptics unable to carry out?
It would be wrong for epileptics to carry out functions where full attention is required and where there is no room for mistakes, like for example learning to drive. Although such constrictions can lead to psychiatric problems in the epileptic patient, with a certain education it will become easier for the patient to accept them.

– It is regarded as strange to see epileptics in positions of high ranking bureaucrat, politician or director. What are the risks associated with epilepsy in positions of decision-making?
This is a critical question. In my opinion, in cases which successfully respond to treatment, are followed-up from a psychiatric point of view and do not present a problem, to be involved in such tasks has no drawbacks.

– People regarded as genius are sometimes called epileptic. How is such a connection established and is it true?
It is quite the opposite, in cases that are uncontrolled and/or resist treatment the intelligence level is low. But of course it is possible to come across epileptics amongst genius, but these are a minority. With regards to public health, the point to remember is that in children who for example have low mathematical abilities, the possibility of epilepsy should be considered and help sought urgently.

– Do epileptic patients suffer from delusions? Do they have hallucinations?
Yes, both during a seizure and after a seizure. Particularly before and in between seizures there is a risk of paranoid delusions and hallucinations. For this reason all cases for which a diagnosis of schizophrenia is considered, should be assessed with this in mind.

– What place does epilepsy occupy in mythology?
Dear Uğur, I don’t know its place in mythology, but in ancient times people believed that the devil had entered the body of the epileptic and they burnt them alive. Thankfully our history has a clean conscience in this regard .…

– When we talk about epilepsy, Alzheimer’s springs to mind. Is there really a connection between the two?
I don’t know of a specific connection. I don’t think so.

– What do you use in the treatment of epilepsy?
We use anti-epileptics. In addition, psychotherapy, family treatment, and education are very important. If there is a psychiatric picture, we take the necessary psychopharmacological and psychotherapeutic steps. In cases that curiously resist treatment, ECT sometimes proves useful. With regards to somatic treatment, techniques like vagal nerve stimulation and TMU have encouraging aspects.