IACAPAP Textbook of Child and Adolescent Mental Health

Chapter

I.2

PAEDIATRICS

EPILEPSY AND RELATEDPSYCHIATRIC CONDITIONS
Eduardo Barragán Pérez

Eduardo Barragán Pérez
MD, MSc
Pediatric neurologist, Hospital
Infantil de México, Federico
Gómez, México & Professorof pediatric neurology,
Universidad Nacional
Autónoma de México, México
Conflict of interest: none
disclosed.

Image: Arthur Toga
This publication is intended for professionals training or practising in mental health and not for the general public. The opinions
expressed are those of the authors and do not necessarily represent the views of the Editor or IACAPAP. This publication seeks todescribe the best treatments and practices based on the scientific evidence available at the time of writing as evaluated by the authorsand may change as a result of new research. Readers need to apply this knowledge to patients in accordance with the guidelines andlaws of their country of practice. Some medications may not be available in some countries and readers should consult the specific drug
information since not all dosages and unwanted effects are mentioned. Organizations, publications and websites are cited or linked toillustrate issues or as a source of further information. This does not mean that authors, the Editor or IACAPAP endorse their content or
recommendations, which should be critically assessed by the reader. Websites may also change or cease to exist.
©IACAPAP 2012. This is an open-access publication under the Creative Commons Attribution Non-commercial License. Use,
distribution and reproduction in any medium are allowed without prior permission provided the original work is properly cited andthe use is non-commercial. Send comments about this book or chapter to jmreyATbigpond.net.au
Suggested citation: Barragán E. Epilepsy and related psychiatric conditions. In Rey JM (ed), IACAPAP e-Textbook of Child andAdolescent Mental Health. Geneva: International Association for Child and Adolescent Psychiatry and Allied Professions 2012.

Epilepsy

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IACAPAP Textbook of Child and Adolescent Mental HealthEpilepsy (from the Ancient Greek ἐπιληψία (epilēpsía): seizure) is a groupof chronic neurological disorders characterized by seizures, which are theresult of abnormal, excessive or hypersynchronous neuronal activity in thebrain (Engel, 2006). Epilepsies can be classified by the:
•
•
•

•
•

Etiology (e.g., idiopathic, secondary – see side box)
Characteristics of the seizures, such as absence, myoclonic, clonic,
tonic, tonic-clonic, and atonic (Blume et al, 2001).
Location in the brain where seizures originate:− Partial or focal onset seizures: simple partial (consciousness is not
impaired) or complex partial (psychomotor seizure). Partial seizures
may generalize (secondary generalized)− Generalized seizures− Frontal, temporal lobe
Medical syndromes of which they are a manifestation (e.g., juvenile
myoclonic epilepsy, Lennox-Gastaut syndrome)
Event, if any, that triggers the seizures, such as reading or music.

Epilepsy is a worldwide problem that affects between 2% and 3% of the
population, 75% of the cases begin before adolescence. Epilepsy can be caused bygenetic, structural, metabolic or unknown factors. Among the structural factors,
the most common causes in developing countries are infectious and parasitic
diseases (especially neurocysticercosis), perinatal brain damage, vascular disease,and head trauma – all preventable (Barragan, 2004). The prognosis of epilepsy
depends on the etiology of the illness as well as on early and sustained treatment.
It is estimated that up to 70% of people with epilepsy can live normal lives if theyreceive proper care.
Epilepsy accounts for 0.5% of the global burden of disease, measured indisability adjusted life years (DALYs), with 80% of that burden corresponding
to the developing countries; this illness accounts for 0.7% of the regional (LatinAmerican) burden of disease. There are no significant gender differences and thehighest burden (2.8%) is found in the 5-14 age group.

Seizure types
Idiopathic (primary)•
Seizures startduring childhood oradolescence•
Genetic origen•
Good respond topharmacologicaltreatment•
Good prognosis,•
No brain damage
Symptomatic(secondary)•Seizures start at any
age•Multiple etiology•
Uncertain
pharmacologicalresponse•
Variable prognosis•
Usually brain damage

The global incidence, prevalence, and mortality of epilepsy are not uniform,
depending on several factors. Developing and developed countries have geographic,
economic and social differences. The prevalence and incidence of epilepsy
are higher in developing countries than in developed ones. However, withindeveloping countries – even given the high incidence of epilepsy – the prevalenceis relatively low, which may be due to high mortality of people with epilepsy.
Prognosis in developing countries seems similar to that in developed ones. Because
phenobarbital, carbamazepine and phenytoin are available and inexpensive, they
are the drugs most often used in developing countries but they produce more
psychiatric side effects. The most cost-effective way to decrease the treatment gap
in developing countries would be to deliver epilepsy services through primary
health care. All these issues have an impact on the existence of higher psychiatriccomorbidity in developing countries.

EPILEPSY AND PSYCHIATRIC DISORDER
Mood, anxiety, psychosis, attention deficit hyperactivity disorder (ADHD)
and autism are relatively frequent comorbidities of epilepsy. Traditionally, these

Epilepsy

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Click on the picture to viewa short video explaining
epilepsy and its types (10:42)

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IACAPAP Textbook of Child and Adolescent Mental Health

Table I.2.1
Prevalence of selected psychiatric disorders in young
people suffering from epilepsy and in the general population
Epilepsy sufferers (%)

General Population (%)

Depression

11-60

12-15

Anxiety19-45

2.5-6.5

Psychosis

2-8

0.5-0.7

ADHD

25-30

2-10

psychiatric conditions were considered to be complications of the seizure disorder
but a bidirectional relationship has now been demonstrated (Gaitatzis et al,2004). Therefore, not only are patients with epilepsy at greater risk of developing
these psychiatric disorders but patients with mood, attention deficit disorders
and autism have a significantly greater risk of developing epilepsy also (Barragán& Hernandez, 2005). These bidirectional relationships suggest the existence ofcommon pathogenic mechanisms operating in epilepsy and the major psychiatricdisorders. An alternative explanation is that both epilepsy and psychiatric illness
are the result of an underlying structural brain abnormality. Thus, identificationof the underlying pathogenic mechanisms may shed light on the neurobiologicalbases of these disorders.
The existence of comorbid psychiatric disorders has a significative impact
on the treatment of epilepsy (Kessler et al, 1994; Bijl et al, 1998). Epidemiologicalstudies show that psychiatric disorders are more prevalent among people withepilepsy than in the general population (Davies et al, 2003; Devisnky, 2003)
as shown in Table I.2.1. Prevalence rates in studies using ICD codes fromadministrative data (Bredkjaer, 1997; Gaitatzis, 2004) are highly variable due tounreliability of the recordings. Studies using structured interviews find even higher
rates. However, prevalence of psychiatric conditions in clinic-based studies may behigher than in the general population because samples are biased toward individuals
seeking medical attention (i.e., sicker). In summary, psychiatric comorbidity inepilepsy is high regardless of the ascertainment method used.

The modern medical eraof epilepsy began withthree English neurologists:
John Hughlings Jackson(pictured), Russell Reynolds,
and Sir William Richard
Gowers. In a seminal
study, Jackson (1835-1911)
defined a seizure as "anoccasional, an excessive,
and a disorderly discharge ofnerve tissue on muscles." Healso recognized that seizures
can alter consciousness,sensation and behavior.
Two independent teamsof chemists createdphenobarbital, which wasmarketed in 1912 by Bayer
under the brand name of
Luminal. Phenobarbital is theoldest antiepileptic drug andis still in clinical use.

The presence of comorbid disorders also impacts on the response toantiepileptic drugs, particularly due to side effects, and on the quality of life ofthese patients. For example, a study by Tellez-Zenteno et al (2007) found that one
third of patients with epilepsy had depression or anxiety, one in four had suicidal
ideas and almost half had problems with attention or cognition.
Significance of the association between epilepsy and psychiatric disorder
There are several explanations for this association:
1. The comorbid psychiatric disorder is the result of an increase inpsychosocial problems (e.g., stigma, impairment) associated withepilepsy
2. Repeated seizures actually increase the vulnerability for psychiatricdisorder3. Psychiatric disorder increases vulnerability for epilepsy

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IACAPAP Textbook of Child and Adolescent Mental Health

4. Both epilepsy and psychiatric conditions are caused by a brain
abnormality
Epidemiologic studies suggest that a previous history of depression may
increase the risk of epilepsy (four to seven fold), while the presence of epilepsy
increases the risk of developing depression (five to 25 fold) (Kanner, 2005).
This data suggest a bi-directional relationship between the two diseases. Other
psychiatric disorders such as ADHD increase the risk of epilepsy 3.7 fold. A study
in Wisconsin including 53 children with newly diagnosed idiopathic epilepsy using
structured interviews showed that one quarter had a depressive disorder before theonset of the seizures, one quarter an anxiety disorder and one quarter ADHD.
Psychiatric comorbidity
Depression
Using DSM-IV criteria, the lifetime prevalence of depression ranges from
12% to 16% and 1-year prevalence is about 5%. Mood disorders are the mostcommon psychiatric conditions found in people with epilepsy. For example,
Grabowska-Gryzb et al (2006) found a prevalence of depression of 49.5% in 203
patients with intractable epilepsy. Rates are highest in populations with intractableepilepsy (40%-60%) but are still high in people with epilepsy in the general
population (about 20%). The timely identification and treatment of depression
in epilepsy is increasingly recognized as an area requiring attention (Davies et al,2003).
Anxiety

Hans Berger, a German
psychiatrist, discoveredthat it was possible torecord the electric currents
generated by neurons in
the brain without opening
the skull, and to record
them on a strip of paper,
which Berger named as
the electroencephalogram(EEG). This discovery
opened the door for aquantum leap on epilepsy
diagnosis and research.

Lifetime prevalence of anxiety disorders in the general population ranges
from 2% to 5% (Hunt et al, 2002). In people with epilepsy, prevalence ranges
from 11% to 15%. Tellez-Zenteno et al (2005) reported a lifetime prevalenceof 13% in a Canadian general population study in adolescents using structured
psychiatric interviews. Anxiety disorders seem to be more common in patientswith intractable epilepsy. Regrettably, depression and anxiety do not seem to lessen
in patients with intractable epilepsy who underwent surgery for epilepsy.
Psychosis
The prevalence of psychosis in the general population ranges between 1%
and 2% (Johns & van Os, 2001). Psychotic symptoms in people with epilepsy
may be ictal (they occur during the seizure, e.g., complex partial seizure), postictal(after having a seizure), or chronic interictal (Table I.2.2). Prevalence of interictal
psychosis in non-selected epilepsy population studies varies from 3.1% to 9%.
They are more frequent in adolescents but children can also show these symptoms,
Table I.2.2•••

Subcategories of epileptic psychoses

Postictal psychosis: psychosis that follows immediately after one or multiple
seizures (mostly complex partial or secondarily generalized), occurring within one
week of the last seizure
Acute interictal psychosis: psychosis that develops when seizures haveceased or reduced significantly in frequency (alternative psychosis) or when
seizures are unrelated to a recent increase in seizure activity
Chronic epileptic psychosis: a psychotic state lasting more than six
months in patients with epilepsy.

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IACAPAP Textbook of Child and Adolescent Mental Healthespecially children with partial complex seizures. In studies of patients withtemporal lobe or refractory epilepsy, prevalence ranges from 10% to 19%, whichis almost double that found in non-selected epilepsy populations (Taylor, 1972).
In children, it is important to highlight that some antiepileptic drugs can trigger
psychotic symptoms (e.g., topiramate, levetiracetam and phenobarbital).
By contrast, the overwhelming majority of individuals with epilepsy neverexperience psychotic episodes, which leads to the long disputed question of whether
there is a relationship between epilepsy and psychosis (Tadokoro et al, 2007).
In cases of interictal psychosis, mostly in temporal lobe epilepsy, there is a longinterval (greater than 10 years since the first seizure) until the onset of psychosis.
Some have suggested the link between epilepsy and psychosis is non-specific andthat psychosis in patients with epilepsy occurs not as a result of the epileptic
activity itself but indirectly as a sequel to non-specific damage to vulnerable partsof the brain. This contrasts with Landot’s (1953) view of psychosis as the result ofa paradoxical normalization of the electroencephalogram in patients with epilepsy.
ADHD
Comorbidity with ADHD is common – it occurs in as many as 30% to 50%
of patients – and may cause serious social and academic impairment (Barragán atal, 2005). The association is independent of epilepsy syndrome, seizure type, ageof epilepsy onset and etiology of seizures. Pharmacologic intervention in patientswith epilepsy and ADHD is particularly challenging due to the potential risk forthe exacerbation of seizures by the ADHD medication. Treatment of ADHD
has traditionally relied on the use of psychostimulants such as methylphenidate.
Unfortunately, side effects like the possibility of increasing seizure threshold andthe number of seizures limit stimulant use. Atomoxetine has shown to be effective
for ADHD symptoms, does not worsen seizures and is generally well tolerated.
The main side effects of atomoxetine are decreased appetite, headaches, nausea andweight changes (Barrágan & Hernández, 2005). There are no interactions between
antiepileptic drugs and ADHD medications.

SYNDROMES, SEIZURES, DRUGS AND MOOD
There has been considerable debate − still unresolved − as to the association
between a particular type of epilepsy and depression. People with epilepsy resulting
from lesions in the temporal lobe are more likely to have intractable seizures, andthey are also more likely to take a larger variety of medications than those withtemporal epilepsy without lesions. Overall, studies have shown that patients withtemporal lobe epilepsy are more prone to depression, particularly those withtemporal lobe epilepsy who had mesial temporal sclerosis. In general, there isagreement that patients with complex partial seizures (the more frequent type of
seizures in temporal lobe epilepsy) are more likely to have a depressive disorder.
Antiepileptic drugs and depression
Interest on the role of antiepileptic drugs in precipitating depression has
grown following the introduction of the new antiepileptic compounds (Mula &Sandeer, 2007), resulting in a revival of the concept of forced normalization. The
antiepileptic drugs more often associated with this effect seem to be those which
act at the benzodiazepine-GABA receptor complex (e.g., tiagabine, topiramate,vigabatrin, carbamazepine and valproate). It is not rare to see mood changes

Epilepsy

I.2

Do antiepileptic
drugs exacerbate oreven induce ADHD
symptoms?
•

•
•

•
•

Barbiturates andspecifically
phenobarbital may
induce hyperactivity
especially in toddlers
Valproate may induce
irritability in newly
diagnosed children
Lamotrigine may
induce hyperactivity inthe developmentallydisabled
Levetiracetam may
induce hostility
Topiramate may induce
both slowing andhyperactivity.

Click on the picture
to view a short video
about how epilepsy isdiagnosed (4:30)

Forced normalization
A hypothesized
phenomenon by which
the sudden cessationof seizures in people
with intractable epilepsy
would be followed by thedevelopment of psychiatric
symptoms – usually
psychotic, but depression is
also reported.

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IACAPAP Textbook of Child and Adolescent Mental Health

EEG recording of anabsence lasting 3 seconds

Antiepileptic
medications

in children when they take these medications, even at low doses, especially inthose with temporal lobe epilepsy. Anecdotal evidence (case reports) suggest thatlevetiracetam can often cause mood symptoms (depression, irritability) as well as
disruptive behavior, which can be ameliorated with a combination of vitamin B6
and B12. There may also be interactions between antidepressant medications andantiepileptic drugs. This largely depends on liver metabolism, thus it is important
to know where medications are metabolized and whether they induce or inhibit
the metabolism of other medications (see Table I.2.3). Antidepressants may
Table I.2.3

Interactions of antiepileptic drugs with liver enzymes

Antiepileptic Drug

Induction

Carbamazepine (95%)
 (75%)
 (90%)
 (50%)
 (50%)
 (90%)
 (45%)
 (40%)

Phenobarbital
Phenytoin
Primidone
Felbamate
Lamotrigine
Oxcarbazepine
Topiramate
Felbamate

Inhibition

CYP3A4CYP2C19; CYP2C9CYP3A4
UGT (weak)
CYP3A4CYP3A4Oxcarbazepine
Topiramate
valproate

Enzymes

Older drugs•
Benzodiacepines•
Carbamazepine•
Clobazam•
Phenobarbital•
Phenytoin•
Primidone•
Valproate
Newer drugs•
Felbamate•
Gabapentin•
Lamotrigine•
Levetiracetam•
Oxcarbazepine•
Pregabalin•
Topiramate•
Vigabatrin•
Zonizamide

CYP2C19
CYP2C19 (weak)CYP2C19
CYP2C19, UGT

Gabapentin
Levetiracetam
Pregabalin
Topiramate (<200 mg/day)Without hepaticinteraction

Vigabatrin

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IACAPAP Textbook of Child and Adolescent Mental Health

Table I.2.4
seizures.

Common psychiatric medications and their effect on

Increase the risk of seizures:• High risk: bupropion, clomipramine, chlorpromazine, clozapine• Intermediate risk: tricyclic antidepressants, venlafaxine, thioridazine, olanzapine,quetiapine• Low risk: fluoxetine, sertraline, paroxetine, trazodone, haloperidol, risperidone.

increase the risk of seizures (Mula et al, 2004). Table I.2.4 lists common psychiatric
medications and their effect on seizures.
BEHAVIOR PROBLEMS
Epidemiologic studies have consistently shown that children with epilepsy
have higher rates of behavior problems than children with other chronic physicalconditions. It is not clear when these problems begin but it is commonly assumed
that they start after epilepsy is diagnosed. The reasons for these behavior problems
are not well understood either. Presumed causes include:••••

The effect of the seizures themselves
Effects of medication
Poor child and family adaptation to the illness, andNeurologic dysfunction that brings about both seizures and behavior
problems.

Types of aggravationof seizures• Re-occurrence of
seizures in previously
controlled patients• Increase in thefrequency or severityof pre-existing
seizures• Emergence of a new
type of seizure or
status epilepticus.

With few exceptions, studies investigating behavior problems have been
conducted on children who had suffered from epilepsy for many years. This makes
it difficult to separate preexisting causes of behavior problems from those related
to living with chronic epilepsy.
Hoare and Kerley (1991) compared psychiatric disturbance across several
small groups of children. Children with new-onset epilepsy were diagnosed andtreatment was initiated within three months before data collection. They foundthat 24% of the children either had behavior problems in the clinical range or wereat risk for such; children with new-onset epilepsy had higher mean total behavior
problems scores than children who had no further seizures. They hypothesized that
central nervous system dysfunction might be a causal factor in both seizures andbehavior problems.
If high rates of behavior problems before the first recognized seizure were
to be found, then behavior problems could not be attributed to side effects ofmedication or to a negative emotional response to epilepsy, such as concerns about
stigma. The percentage of children with previously unrecognized seizures who had
behavioral problems in the clinical range (34.2%) is similar to the rate of psychiatricdisturbance found in children with a brain disorder (including seizures) in the Isleof Wight study (34.3%). This finding of higher rates of behavior problems at thetime of onset of seizures in children who had unrecognized epilepsy is consistent
with Aicardi and Ohtahara’s (2002) hypothesis that epilepsy can be a pervasive
condition in children.
Thus, emotional and behavioral disturbances are common among children
with epilepsy and can cause serious social and academic impairment with longterm effects. Management of the behavioral problem of these children is similar

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IACAPAP Textbook of Child and Adolescent Mental Healthto that of children without epilepsy (e.g., psychoeducation, parent management
training, CBT and medication). Pharmacologic intervention in patients withepilepsy and disruptive behaviors is particularly challenging due to the potential
risk for exacerbation of seizures by the medication. So far, very few data exist
on the efficacy and safety of typical and atypical neuroleptic medications inepileptic children. Moreover, despite the apparent consensus among physicians,no conclusive data exist on whether commonly used psychotropic drugs such as
SSRIs and tricyclic antidepressants worsen seizures (see Table I.2.4), but they need
to be used with caution. Antipsychotics, such as risperidone and olanzapine, andmethylphenidate can be safely used in patients with epilepsy.
Most of the available information on the use of neuroleptic medicationsin epileptic children comes from older reports using first generation neuroleptics,
such as thioridazine and haloperidol. Although effective in reducing disruptive
behaviors, nowadays these drugs are prescribed less frequently because of adverse
effects, both neurological and cardiovascular (thioridazine, for example, is nolonger available in some countries). Second generation neuroleptic drugs such as
risperidone and olanzapine cause fewer extrapyramidal symptoms. Risperidone,
and sometimes olanzapine, has been shown to be very efficacious in diminishing
behavioral disturbance in developmentally disabled children in the short term, in
those with autism and pervasive developmental disorder as well as in patients withepilepsy, without an increase in the number of seizures (Barragán et al, 2005).

SLEEP AND EPILEPSY

Click on the picture to accessthe NICE guidance on the
diagnosis and managementof the epilepsies in adults
and children.

Since Aristotle and Hippocrates noted the occurrence of epileptic seizures
during sleep, the relationship between sleep and epilepsy has intrigued physicians
and researchers. Sleep is an example of a physiologic state capable of modulating
seizures. The influence of sleep on epilepsy is supported by the observation thatin specific epileptic syndromes seizures occur exclusively or primarily during nonrapid eye movement (NREM) sleep. In almost all epileptic syndromes, interictal
epileptiform discharges are more prevalent during NREM sleep and less prevalentduring rapid eye movement (REM) sleep.
The proportion of patients who have seizures that occur exclusively or
predominantly during sleep ranges from 7.5% to 45% in several series studying
sleep-related epilepsy. This wide variation may reflect differences among patient
populations, with seizures more likely to occur during sleep in certain epileptic
syndromes. Frontal lobe seizures are more common during sleep and temporal
lobe seizures more common during wakefulness (Commission on Classification
and Terminology of the International League Against Epilepsy, 1989). Herman
and coworkers (2000) analyzed 613 seizures in 133 patients with partial seizures
who underwent video-EEG monitoring finding that 43% began during sleep, themajority during stages 1 and 2 NREM sleep and none during REM sleep.
As the clinical manifestations of nocturnal frontal lobe seizures often include
prominent tonic or motor manifestations, they are more likely to be noticed by thepatient or family than complex partial seizures of temporal lobe origin – complex
partial seizures that begin focally and impair consciousness are the predominantseizure type in temporal lobe epilepsy. However, the brevity, the minimal or lack of
postictal confusion, the apparently psychogenic features (such as kicking, thrashingand vocalizations), and the frequently normal interictal and ictal recordings may
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IACAPAP Textbook of Child and Adolescent Mental Healthcomplicate diagnosis. Nocturnal seizures may suggest diagnoses of sleep terrors,
REM sleep behavior disorder, psychogenic spells, or nocturnal paroxysmal dystonia.
Seizures originating in the sensorimotor area may be mistaken for psychogenic
spells because of thrashing behavior, preservation of consciousness, absence ofpostictal confusion, and absence of interictal or ictal EEG activity. Diagnostic
features supporting sensorimotor area seizures include (1) short duration (lessthan 30 seconds to a minute), (2) stereotyped nature, (3) tendency to occur
predominantly or exclusively during sleep, and (4) tonic contraction of the arms
in abduction. Psychogenic spells usually are of longer duration (one to several
minutes), are nonstereotypic, and occur when the patient is awake or drowsy.
Nocturnal paroxysmal dystonia. This syndrome, initially termed hypnogenic
paroxysmal dystonia and subsequently, nocturnal paroxysmal dystonia, ischaracterized by brief (15-45 seconds) stereotyped motor attacks consisting ofdystonic posturing, ballistic or choreic dyskinesias and vocalizations during NREM
sleep without clear ictal or interictal EEG changes.
Differential diagnosis
The differentiation of nocturnal seizures from non-epileptic spells during
sleep can be challenging. First, in partial seizures occurring during wakefulness,patients may report postictal confusion or recall the beginning of a seizure (aura)that precedes loss of consciousness. These elements of the history support thediagnosis of epilepsy and frequently are absent in seizures occurring during sleep.
Second, nocturnal events may not be observed properly. Bed partners may not
be present or, if present, may not be fully awake and coherent. Complex partial
seizures of temporal lobe origin in particular may lack vigorous motor activity andmay fail to wake the bed partner. Third, a variety of sleep disorders are characterizedby vigorous movements and behaviors that mimic seizures. Finally, certain typesof seizures, particularly those of frontal lobe origin, are manifested by bizarre
movements suggestive of a psychiatric disorder, including kicking, thrashing, andvocalizations. These epilepsies may be associated with normal ictal and interictal
EEGs and normal imaging studies, making definitive diagnosis difficult.
Arousal disorders
NREM arousal disorders include a spectrum of confusional arousals,
somnambulism (sleepwalking), and night terrors. These three disorders share thefollowing features:•••

They usually arise from NREM sleep stages 3 or 4 and, therefore,
occur preferentially in the first third of the sleep cycle
They are more common in childhood, andThere is often a positive family history, suggesting a genetic
component.

Broughton (1968) contrasted confusional arousals – characterized bybody movement, autonomic activation, mental confusion and disorientation,and fragmentary recall of dreams – with the nightmares of REM sleep (in which
subjects became lucid almost immediately and usually recall dreaming).
Somnambulism is a related NREM arousal disorder in which patients may
wander out of the bedroom or house during confusional episodes. Night terrors
begin with an intense scream followed by vigorous motor activity. Children often

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IACAPAP Textbook of Child and Adolescent Mental Healthare inconsolable and completely amnestic for the event. The subject appears to be
awake but is unable to perceive the environment. If mental activity preceding theevent is recalled, the images are simple (e.g., face, animal, or fire) compared withthe complex plots of REM nightmares. Patients often report an oppressive feeling,such as being locked up in a tomb, or having rocks piled on their chests. Intense
autonomic activation results in diaphoresis, mydriasis, tachycardia, hypertension,and tachypnea. In contrast to seizures, NREM arousal disorders are less stereotyped
and commonly occur in the first third of the night. Patients with REM-sleep
behavior disorders often present with vigorous motor activity during sleep andmay injure themselves or their bed partners.
Sleep-related movement disorders
Movement disorders occurring during sleep that may resemble seizures
include periodic limb movements, sleep-onset myoclonus, bruxism, and rhythmic
movement disorder.
•

•

•
•

Periodic limb movements in sleep may result in vigorous kicking or thrashing.
A history of restless legs syndrome is commonly elicited. In contrast to
seizures, periodic limb movements occur at periodic intervals (usually every
20 to 40 seconds) and involve a characteristic flexion of the leg, although theupper extremities occasionally may be involved.
Sleep-onset myoclonus, also known as sleep starts, sleep jerks, or hypnic jerks,
is a normal physiologic event occurring at the transition from wakefulness
to sleep, often associated with sensory phenomena, including a sensation offalling. In contrast to myoclonic seizures, sleep-onset myoclonus is limited tothe onset of sleep.
Bruxism, stereotyped teeth grinding resembling the rhythmic jaw movementsof epilepsy, may lead to excessive tooth wear, which does not occur in epilepsy.
Rhythmic movement disorder, also known as head banging or body rocking, canoccur during any sleep stage. It is manifested in a variety of ways, including
recurrent banging of the head while the patient is prone or rocking of the bodyback and forth while on hands and knees. Vocalizations may accompany therepetitive movements. Rhythmic movement disorder can occur at any age,although it is more common in children than adults and is associated withmental retardation. Although complex partial seizures, particularly those offrontal lobe origin, may include similar behaviors, bilateral body rocking ismore characteristic of rhythmic movement disorder. Body rocking may also
occur in psychogenic seizures.

Psychiatric symptoms
Psychiatric symptoms during sleep that resemble seizures include panic
attacks, post-traumatic stress disorder symptoms and psychogenic seizures. Somepatients who have panic disorder present exclusively or predominantly with panic
attacks that cause multiple abrupt awakenings. Symptoms on awakening include
apprehension and autonomic arousal with palpitations, dizziness and trembling.
In contrast with REM sleep nightmares, dreams are not recalled. In contrast withnight terrors, which arise during deep NREM sleep, sleep panic attacks usuallyoccur in the transition from NREM stages 2 to 3. Although a history of daytime
panic attacks can be useful diagnostically, panic attacks may occur exclusively
during sleep. An abrupt return to consciousness and autonomic arousal is morecharacteristic of panic disorder than of seizures, although these features may occur

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IACAPAP Textbook of Child and Adolescent Mental Healthin seizures. Simple partial seizures of parietal lobe origin may manifest occasionallyas panic symptoms.
In post-traumatic stress disorder, repetitive rocking or head banging may
occur, and the characteristic nightmares or flashbacks may arise at any stage ofsleep. In contrast to seizures, patients often recall the traumatic experience.
Psychogenic seizures may occur while the patient appears to be asleep. Diagnosisof these non-epileptic events is supported by the presence of a well-organized
posterior alpha rhythm immediately before the onset of clinical changes despite
the patient appearing to be asleep and the lack of ictal or postictal EEG changes.
Provocative testing with suggestion may be helpful in confirming the diagnosis of
psychogenic seizures.

QUALITY OF LIFE IN PEDIATRIC PATIENTS WITH
EPILEPSY
One Latin-American study including more than 200 patients between
six and 18 years of age showed that the quality of life of these patients was fair
(López-Rojas et al, 2010). Almost half of the patients felt stigmatized. Income,the number of antiepileptic drugs and their cost, school performance and stigma
were the factors which influenced quality of life. This is similar to results in otherregions of the world (Devinsky & Penry, 1993).
The type of seizure is important. The principal neurocognitive difference
between the two types of focal epilepsy (frontal vs temporal) is IQ (mean IQ of 82
in frontal epilepsy and 97 in temporal epilepsy), with more impact in the working
memory and visuospatial performance in children with frontal epilepsy. Patientswith temporal lobe epilepsy have more problems with attention and long term
memory tasks (Barragán et al, 2006).

Click on the picture toview a short video aboutliving with epilepsy(4:21).

ADHD, cognitive decline and academic performance is one of the principal
mental health problems worldwide in childhood epilepsy. In another LatinAmerican study, important differences between countries were noted, especiallyin the severity of ADHD, academic performance (lower in Central Americancountries) and better response to treatment in countries with a better education
system.

TREATMENT
Most low income countries have access to the four basic antiepileptic drugs(phenobarbital, phenytoin, carbamazepine, and valproate) but only at secondary
and tertiary levels of care. Ensuring supply of these four medications is essential,
taking into account that seizures can be controlled with monotherapy regimens
in up to 70% of cases. In 1990, the WHO determined that the average cost oftreatment (with phenobarbital) could be as low as US$ 5 per patient per year
(World Health Organization, 2006). Public health services in most of thesecountries do not have access to the new-generation antiepileptic drugs, useful intreatment resistant cases but more expensive.
In the integrated management of people with epilepsy, consideration of
psychosocial factors is essential and includes education for self-management; thatis, measures and behaviors that people with epilepsy should adopt and maintainto control their illness. In some cases, complementary and alternative medicine

Epilepsy

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IACAPAP Textbook of Child and Adolescent Mental Healthcan also be helpful; including, for example, natural remedies, vitamins, relaxation
techniques, a healthy diet, religious or cultural activities, and social support. Suchmeasures are acceptable as long as the patient continues taking the basic drug
therapy, which treats not only the seizures but also the psychiatric comorbidities.
Rehabilitation
The objective of rehabilitation is to improve the quality of life of people withepilepsy and help them integrate into society and work. The interventions selected
will depend on the complexity of each case. Most people with epilepsy enjoy
substantial autonomy and only a minority suffers from severe forms of the illness.
This group includes persons with disabilities and people who are institutionalized
or highly dependent on their families, in whom developing social and occupational
skills is essential.
As already highlighted, there is a high proportion of psychiatric conditions
comorbid with epilepsy, often unrecognized and therefore not treated properly.
These disorders include depression, anxiety and psychosis, as well as cognitiveand personality changes. Epilepsy associated with psychosis or dementia is often
confined to psychiatric hospitals or social welfare institutions.

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