Neuropsychiatric Symptoms of Epilepsy

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H.Y. Elnazer and N. Agrawal
Depression Scale was used. These can be useful for the assessment of PBCs but may
not be routinely required [ 15 ].
Clinical Description/Presentation
Epilepsy is often complicated by behavioral symptoms including aggression or
various psychiatric disorders. Behaviour symptoms associated with epilepsy may
be pre-ictal, ictal, post ictal or inter ictal [ 16 ]. Seizures-related behavioral changes,
including aggressive behaviors, have been interpreted as the emergence of “archeical”
or innate motor patterns [ 17 ].
One third of patients with epileptic seizures—especially secondarily generalized
seizures—develop pre-ictal prodromal symptoms hours to days before the
seizures. These can include mood changes or depression, irritability, restlessness
or motor hyperactivity, and poor frustration tolerance; all of which can lead to
aggressive or emotional outbursts. These symptoms are often relieved by the occurrence
of the seizure although might persist for few days afterwards. It has been
suggested that these prodromal symptoms may represent biophysiological processes
involved in initiation of abnormal emotions and seizures or a subclinical
seizure activity [ 16 ].
Ictal behavioral symptoms occur in nearly in 25 % of auras (especially when
long), following a cluster of complex partial and secondary generalized seizures of
temporal lobe epilepsy (TLE) or non-convulsive status epilepticus [ 18 ]. These can
include depression (which ranges from mild sadness to profound hopelessness,
despair feelings of anhedonia, guilt, and suicidal ideation) [ 16 ], fear, distress, nervousness,
anger, irritability, panic attacks, phobias [ 19 , 20 ], forced thinking, obsession
[ 12 , 13 ], and aggression [ 21 ]. Ictal aggression is unorganized and accidental.
Directed aggression towards people is observed as resistive aggression as a result of
physical restraint in the context of ictal confusion [ 22 ].
Ictal behavioral symptoms tend to be stereotyped, paroxysmal, of brief duration,
and unprovoked by environmental stimuli. These are sometimes associated with
other characteristics of temporal discharges such as bizarre behavior, mutism and
amnesia, depersonalization and déjà vu, as well as automatism and altered consciousness
[ 23 ].
Post-ictal behavioral symptoms occur after seizures, particularly with TLE and
last hours to days. The symptoms include anxiety, dysphoria, depression, psychosis,
suicidal ideas, and transient aggression [ 24 – 26 ]. Aggression is frequently reported
in post-ictal confusional states or post-ictal psychoses. Post-ictal psychosis might
ensue between 12 h and up to 7 days following the seizure episode, with symptoms
lasting from few hours to few days or rarely for up to 4 weeks. Post-ictal psychosis
may be associated with irritability and aggression along with affective and psychotic
symptoms [ 25 ].
Inter-ictal behavioral symptoms are often mild and spontaneously reversible
[ 27 ]. Complex partial seizures (CPS) of temporal lobe origin may be accompanied