Neuropsychiatric Symptoms of Epilepsy

4 Anxiety
55
Ictal anxiety is frequent in right temporal lobe epilepsy [ 9 ] and rare in extratemporal
epilepsy [ 10 ]. It seems to be reported by 10–15 % patients with partial seizures
[ 11 ], is more common in women than men [ 12 , 13 ], and seems to have a poor
prognostic value for surgery [ 14 ]. Ictal anxiety can be differentiated through a careful
history-taking, with special attention to the association between the duration of
the attacks and the presence of accompanying nonparoxysmal symptoms of an anxiety
disorder like avoidance behavior or the “circle of fear.” Linguistic methods may
be helpful in the differential diagnostic process [ 15 ]. Although not in the narrow
focus of this chapter, it should be mentioned that dissociative seizures also may go
along with anxiety. Persons with dissociative seizures described a greater number of
somatic symptoms of anxiety during the attacks when compared to persons with
epilepsy [ 16 ].
Structured interviews are of value in establishing the diagnosis of an anxiety
disorder [ 17 ]. They form a gold standard, but screening instruments that are easy
and quick to administer are helpful in a busy clinic. A widely used screening instrument
for anxiety disorders is the GAD-7 [ 18 ], which may also be used in the context
of epilepsy. It is only recently that a Korean version of this instrument has been validated
in persons with epilepsy [ 19 ].
Harter et al. reported on a patient who had had a few generalized tonic-clonic
seizures in his youth and subsequently developed agoraphobia with panic disorder
[ 20 ]. This man had had a couple of self-induced seizures, and sometime after
refraining from inducing seizures, he developed anxiety that was first suspected to
be of epileptic origin. EEG and MRI were normal, and thorough history-taking led
to the correct diagnosis. Psychotherapy relieved the symptoms. One remarkable
feature of this case is that the patient had only had a few seizures and that these were
moreover self-induced, and that he, despite this, developed an anxiety disorder.
Postictal psychiatric symptoms have been studied thoroughly using a questionnaire
of 42 items answered by 114 patients with regard to a period of 72 h after a
seizure [ 21 ]. Anxiety was the most frequent postictal emotional symptom, experienced
by 45 out of the 114 patients. This is not only of theoretical interest but has
also therapeutic implications. It means that some patients deserve special attention
during the first 3 days following a seizure, because of emotional disturbances.
Anxiety is high in patients who report stress – acute or chronic – as seizureprecipitant
[ 22 – 24 ]. Many persons with epilepsy attribute seizures to stress, though
it is not yet clear in how many of them this is a true seizure-precipitant, maybe
mediated by high levels of anxiety, or a mere attribution that is driven by anxiety.
Epidemiology
Several studies have assessed the prevalence of comorbid anxiety in people with
epilepsy, applying different methods (telephone interviews, mailed questionnaires,
direct contact in the clinic as ways of approaching the patients, and self-assessment
or psychological examination as ways of assessing symptoms resp.