Neuropsychiatric Symptoms of Epilepsy

60
C. Brandt
to the speculation that an improvement of anxiety may lead to an improvement of
epilepsy, which again touches the field of the bidirectional relationship between
both diseases.
Epilepsy patients treated with add-on levetiracetam (LEV) for their seizure disorder
showed significantly less anxiety after LEV was added [ 79 ]. This was, however,
only true for the subgroup that had an improved seizure frequency and is thus
not a specific anxiolytic effect of LEV. This finding is therefore in line with the
above-mentioned studies showing improvements of anxiety symptoms after successful
epilepsy surgery. Anxiety has – among other psychiatric conditions – also
been reported as a side effect of LEV [ 80 ].
An important point is the collaboration between neurologists and psychiatrists,
at least if the treating physician does not unify both specialties in one
person. It has been hypothesized that neurologists and psychiatrists do not
cooperate to the extent they should and in the way they used to previously [ 81 ].
It has been advocated to train neurologists in recognizing and treating psychiatric
disorders, and to psychiatrists, vice versa [ 82 ]. An embedded psychiatrist
within an epilepsy service may lead to amelioration of comorbid psychiatric
symptoms by initiating or adjusting pharmacological treatment or by delivering
time-limited psychotherapy [ 83 ]. Many European epilepsy centers have dedicated
services for persons with epilepsy and comorbid psychiatric disorders
( http://www.mara.de/fileadmin/Krankenhaus_Mara/downloads/ezb_
verhaltensmed_u_psychoth_epileptologie_201408.pdf.pdf ) [ 84 ]. These are
wards, where neurologists, psychiatrists, specialized nurses, and other healthcare
professionals, for instance, occupational therapists, work together in an
interdisciplinary setting applying drug therapy and psychotherapy. These institutions
take account of the high comorbidity, not only of epileptic and dissociative
seizures but also of epilepsy and psychiatric disorders, for example, anxiety.
This is in fact a paradigm of the concept of comprehensive care for people with
epilepsy [ 85 ].
Psychotherapy
Cognitive-behavioral therapy (CBT) has been shown to improve anxiety in patients
with epilepsy [ 86 ] in a noncontrolled study in a small group of patients and is
regarded as the psychotherapeutic procedure with the highest evidence in favor
[ 76 ]. Psychodynamic therapy is second-line [ 76 ]. It has, however, to be questioned
that an approach with a standard manual is adequate. Probably, a specific program
for people with epilepsy and anxiety symptoms should be designed. Combination of
pharmacotherapy and psychotherapy has been advocated. Amygdala hyperactivation
has been found to normalize after exposure therapy [ 87 ], which shows an
organic correlate of the efficacy of this psychotherapeutic procedure.