EPILEPSY IN CHILDREN AND ADOLESCENTS: WHAT A PSYCHIATRIST SHOULD KEEP IN MIND

Abstract

Certain types of epileptic seizures can be mistaken for psychiatric manifestations. Complex partial seizures may present with changes in autonomic nervous system function, somatosensory auras, difficulties in speech, attention or movement, stupor, intense motor behavior, posturing, aimless wandering, changes in perception of place, time or persons, illusions and hallucinations. These phenomena are not usually accompanied by loss of consciousness.

Temporal epilepsy exhibits prodromal symptoms, such as headache, irritability, insomnia, personality changes and a sense of imminent harm. Common symptoms include auras, déjà vu - jamais vu, dreamy states, feelings of fear and strangeness, automatisms, tonic-dystonic posturing of extremities, transpiration, dizziness, faintness, tachycardia, hypoxia, disordered consciousness. The seizure may be followed by confusion, tiredness, disorientation, headache, automatisms, impaired attention, memory and learning, hyperactivity, oppositionality, panic attacks, dissociation, and obsessive-compulsive symptoms.

In frontal lobe epilepsy, three types of seizures may be mistaken for psychiatric problems:  hyperkinetic seizures, tonic seizures of complementary movement area, and absences. In absences, the EEG reveals pathological findings, whereas in one third of hyperkinetic seizures the EEG findings are normal. The complex and emotionally charged behavior of hyperkinetic seizures, and occasionally of  tonic seizures, combined with a normal EEG, may lead to the misdiagnosis of  a psychiatric disorder such as psychosis, dissociation, conversion disorder, panic attacks or  parasomnias.

Auras are sensory or psychic seizure phenomena. Sensory auras resemble simple hallucinations. Psychic auras are complex hallucinatory experiences that comprise autoscopic phenomena, a sense of someone’s presence, déjà vu - jamais vu, fear and elation.

The limbic system has a prominent role in the initiation and persistence of psychokinetic seizures. Limbic seizures are  associated with  the emergence of psychiatric symptoms.

The diagnosis of epilepsy is mainly clinical; thorough history-taking is of paramount importance. A single surface EEG can neither confirm nor exclude epilepsy. Serial EEGs during wakefulness, in combination with prolonged sleep recordings or video-EEG monitoring, increase diagnostic accuracy.

Antiepileptic drugs may have a negative impact on mental functioning. Possible adverse effects can be reduced with gradual dose titration, dose reduction, use of extended release medications and drug selection according to its adverse effects profile.