Neuropsychiatric Symptoms of Epilepsy

15 Stress and Epilepsy
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intruder in her home. Sometime after this she presented to her general practitioner
with daily episodes of sudden fear and panic, which were attributed
to stress. Despite counseling the attacks worsened, and by age 36 were
interrupting activities with brief periods of amnesia, described by her husband
as associated with episodes of being fidgety and pacing around over
20–30 s, sometimes with injuries. Citalopram had been added, without benefit
and aged 39 she sought a private neurology opinion – a diagnosis of
temporal lobe epilepsy, supported by left temporal abnormalities on MRI
and EEG. However, despite witnessing a typical attack, the neurologist felt
she also had post-traumatic panic attacks and continued to reinforce stress
management approaches. As there was only marginal benefit with the levetiracetam,
she was referred for a specialist epilepsy opinion aged 40, where
pre-surgical evaluation was commenced in addition to switching her levetiracetam
to lamotrigine, and withdrawing the citalopram. Video EEG subsequently
confirmed all of her attacks were focal seizures. On Lamotrigine
she has at the time of writing had no daytime attacks for over 2 years, and
only infrequent attacks from sleep so has deferred further investigation.
A considerable body of work in this area, both pre-clinical and clinical, illustrates
that although potential mechanisms have been well elucidated, the association
between stress and epilepsy is complex. This chapter will explore what evidence
there is from both clinical and basic scientific research to support any causal association
between stress, the occurrence of seizures and epilepsy, with a view to
informing both future research and clinical practice.
Stress is defined as the physiological and/or behavioral response to an event or
events that are interpreted as threatening to the well-being of the individual response
[ 1 ]. Stress is a widely used term in lay, physiological, and psychological contexts,
each with a different perspective. Precipitating events can be physical, environmental,
psychological, and pharmacological. Most stress now is not life threatening but
psychosocial, with both interpersonal and environmental contributors that are perceived
as straining or exceeding the individuals’ adaptive capacities. The element of
perception is key, and reflects individual differences in personality, as well as physical
or health differences. Nonetheless, however defined, stress is present to a greater
or lesser extent for all of us at times throughout life.
Many known triggers for seizures (in some cases also leading to epilepsy) are of
themselves stressful, for example traumatic brain injury, alcohol withdrawal, acute
stroke, which we will not be discussing other than where stress has been considered
as a specific contributor. Similarly it is self-evident that for most the occurrence of
a seizure, or a diagnosis of epilepsy per se, is a stressful event both at the time, and
for some more chronically. It is also well recognized that there is a high prevalence
of anxiety and depression in patients with epilepsy. These topics are covered in
detail in Chaps. 2 and 4 and will not be further discussed here, other than in relation
to the potential interaction with stress and seizure control. Finally, it is important to