Psychiatric Comorbidity in Epilepsy

Psychiatric Comorbidity in Epilepsy: Basic Mechanisms, Diagnosis, and Treatment

H. Mc-Connell, Peter J. Snyder, editors

Washington (DC): American Psychiatric Press; 1998

ISBN 0-88048-853-0 (hardcover)

There is a fascinating and complex interrelation between psychiatric pathology and epilepsy. Historically, epilepsy was known as the “sacred” disease because of its alleged association with astrology, with the divine, and with demoniacal possession. Despite Hippocrates’ assertion that epilepsy “is no more divine nor more sacred than other diseases, but has a natural cause like other diseases,” these misconceptions continued until well into the 19th century, when the neuropathologic origins of epilepsy were identified.

However, the association between epilepsy and psychiatric illness did not cease when it was identified as a neurologic condition. People with epilepsy have an increased prevalence of both affective and schizophreniform disorders. Personality and adjustment disorders are common and seizures may be simulated by conversion states. Epilepsy also has profound socioeconomic implications for the sufferer. It is perhaps therefore the “psychosomatic” illness par excellence.

This book is a compendium of the psychiatric conditions associated with epilepsy. Its 12 chapters cover the historic, physiologic, pathologic, clinical and social aspects of epilepsy. There is an excellent chapter on the changing systems of classification of the epilepsies; the current international classification bears little resemblance to the systems used even 50 years ago. The advent of sophisticated investigative techniques for studying neuronal activity, such as EEG recordings and neuroimaging, has given this system a firm neuroanatomical basis, and has helped to integrate the neuroanatomical changes with the clinical seizure pattern.

There are excellent chapters on the neuropsychological assessment of patients with seizures, and on the mood disorders and psychoses associated with epilepsy. The latter chapter is of particular interest because recent developments have shown that there are lesions in the medial temporal structures of the brain in both epilepsy and schizophrenia. This etiologic overlap may explain not only the increased prevalence of schizophreniform psychoses in patients with epilepsy, but also suggests that there may be a neurophysiologic overlap at the neurotransmitter level between these seemingly disparate conditions.

Perhaps the 2 most useful chapters in the book are those on pharmacology. One reviews the behavioural effects of antiepileptic drugs, the other discusses the treatment of psychiatric disorders in patients with epilepsy. They provide an excellent state-of-the-art summary of the pharmacology of epilepsy and give many practical suggestions about the use of psychotropic agents and their effects on seizure threshold.

The book ends with 2 chapters on the “social” part of biopsychosocial aspect of epilepsy: one on family systems theory and the other, written by a man with epilepsy, entitled “Living with Epilepsy.” The latter is of special interest because the experiences he describes and the problems he raises are not dealt with elsewhere in the book. For example, he describes memory dysfunction, post ictal pain, social rejection and communication difficulties with his neurologists — experiences that are surely not unique to people with epilepsy. It would have rounded out the book if these consumer-driven issues had been dealt with in the clinical sections.

There are weaknesses in the book. The history of epilepsy is long and colourful and it is unfortunate that it is described here in a trite and cliche-ridden way. The chapter on diagnosis and treatment of nonepileptic seizures was superficial and unhelpful. It is puzzling why such seizures should be described in negative language when acceptable terms such as “conversion” or even “hysterical” seizures are available.

On the whole, however, this is a comprehensive, well structured and well referenced book. Each chapter ends with a conclusion that summarizes the main points in that chapter. I was very glad also to see

a uniform and consistent use of the term “people with epilepsy” rather than “epileptic” throughout the book. The word “epileptic” brands the sufferer in a pejorative manner and reinforces the very stigma we try to avoid. If only psychiatrists would similarly use the term “people with schizophrenia” rather than “schizophrenics”!

This book is highly recommended to psychiatrists, neurologists, neuropsychologists and others who see people with epilepsy in their practice.