Neuropsychiatric Symptoms of Epilepsy

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A.A. Sardesai and H. Ring
and a decrease in previous levels of functional abilities may all suggest significant
lowering of mood. However, people with a learning disability often already lead relatively
restricted lives and it can be harder to identify change in functioning at an early
stage. Diagnosing delusions and hallucinations may be particularly difficult as manifestation
of these symptoms generally requires well- developed speech. Thought disorder
may also be difficult to identify in somebody whose behavior and communications
may already be difficult to follow. It should also be kept in mind that the same symptom
can present differently in patients depending on the level of their learning
disability.
There is also the complex issue of equivalence of diagnoses to consider. For
instance, how might somebody with severely impaired language and understanding
experience auditory hallucinations or persecutory delusions. Thus for those with the
most severe learning disabilities, it remains unclear whether behavioral disturbances
that appear to indicate psychological distress are indicating mental states such as
depression or psychosis that are equivalent to such states as experienced by those
with higher IQs. The diagnosis of psychotic states may be particularly problematic
in this context and this may relate to the observation that there are increased rates of
depression and psychosis in those with moderate compared to those with severe or
profound LD.
Particularly in the context of these challenges it is of critical importance to
remain alert for signs and symptoms suggestive of psychiatric states in people
with LD and epilepsy. At the same time it is equally important to consider whether
the presentations of apparently psychiatric states are either manifestations of other
illnesses and/or pain, or are psychiatric consequences of physical illness that has
not been diagnosed. Similarly, adverse effects of AEDs and other medications are
not uncommon and in people not able to report these verbally, clinicians should
remain alert to such effects as the cause of behavioral or emotional symptoms.
This issue can be addressed through careful and thorough history taking and
searching for physical adverse effects of treatment that may go alongside psychiatric
effects.
The role of informants: Collateral history takes on the utmost importance for
patients who cannot tell the clinician what the problem is. While they might communicate
“something is not quite right” it might be only someone close to them who
is able to articulate “what” is not right. How robust the collateral history is depends
on how long the carers have worked with the patient, how well versed they are in
their observations of the patient and also what facets they see. Different carers often
have different ways of working and different perspectives to offer which can lead to
quite different collateral histories regarding nature, onset, duration and progression
of the difficulties stated. The skill of the clinician lies in being able to fit in the
different pieces of the jig-saw offered so as to form a coherent picture, arrive at a
formulation and then come up with a management plan that can be effectively
shared with the patient and carers so as to enable the patient to be supported
effectively.