Neuropsychiatric Symptoms of Epilepsy

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D.W. Dunn and W.G. Kronenberger
Studies of children and adolescents with BECTS have found an association between
frequency of EEG discharges and problems with attention. In addition, as the epileptiform
discharges abate, attention returns to normal [ 90 ]. In a sample of children
with frontal lobe seizures, Zhang et al. [ 91 ] found that 89 % of children with frontal
spikes on the most recent EEG had ADHD compared to 25 % of children with a
normal EEG. Ibrahim et al. [ 92 ] combined fMRI and magnetoencephalography to
show that changes in intrinsic connectivity networks including default mode and
dorsal attention networks secondary to epileptiform discharges were associated
with cognitive impairment.
Both inattention and hyperactivity have been adverse side effects of phenobarbital
and the benzodiazepines [ 93 , 94 ]. Impaired attention and executive functioning
and decreased speed of responsiveness have been related to use of topiramate [ 95 ].
Glauser et al. [ 96 ] showed that sodium valproic acid had more negative effect on
attention than ethosuximide or lamotrigine in children with absence epilepsy. In
contrast, one small study of children with ADHD and spikes on EEG found that
when treatment with valproic acid reduced spikes, there was improvement in attention
[ 97 ]. In an fMRI study, Wandschneider et al. [ 98 ] found normalization of deactivation
of the default mode network in patients receiving levetiracetam.
Psychosocial stressors related to epilepsy are probably not a factor in causing
problems with attention or executive function. Rodenberg et al. [ 99 ] performed a
meta-analysis of 46 studies of psychopathology in children with epilepsy and other
chronic illness. They found that attention problems were relatively specific to epilepsy
whereas anxiety and depression were in part associated with the presence of
chronic illness. It is possible that anxiety and depression, both common comorbidities
in children, adolescents, and adults with epilepsy, could negatively impact the
ability to attend and concentrate.
Treatment of Problems of Attention in Children with Epilepsy
Children with ADHD alone respond well to the stimulant medication. Biederman
and Faraone [ 100 ] report effect sizes of 0.9–0.95 for stimulants and 0.6 for nonstimulants
used to treat children, adolescents, and adults with ADHD. Consensus
statements suggest starting with either methylphenidate or amphetamine, switching
to the stimulant not previously used if patients fail to respond or have side effects
and utilizing atomoxetine if stimulants are not effective or cause adverse effects
[ 101 ]. Next choices are antidepressants such as bupropion or tricyclic antidepressants
and adrenergic agents such as clonidine and guanfacine. A similar approach
with some modifications can probably be used in patients with epilepsy. However,
the data for this recommendation are much weaker for people with epilepsy and
ADHD than for patients with ADHD alone. See Table 13.2 for treatment of attention
problems with people with epilepsy.
For the most part, the old worries that stimulants might worsen seizures have
abated. There is very little data to suggest that stimulants may lower the seizure