Epilepsy

EPILEPSY

Other epilepsy management issues (beyond seizures)

Interictal Behavior The adverse effects of epilepsy often go beyond the occurrence of clinical seizures, and the extent of these effects depends largely upon the etiology of the seizure disorder, the degree to which the seizures are controlled, and the presence of side effects from antiepileptic therapy. Many patients with epilepsy are completely normal between seizures and able to live highly successful and productive lives. In contrast, patients with seizures secondary to developmental abnormalities or acquired brain injury may have impaired cognitive function and other neurologic deficits. Frequent interictal EEG abnormalities have been shown to be associated with subtle dysfunction of memory and attention. Patients with many seizures, especially those emanating from the temporal lobe, often note an impairment of short-term memory that may progress over time.

Patients with epilepsy are at risk of developing a variety of psychiatric problems including depression, anxiety, and psychosis. This risk varies considerably depending on many factors, including the etiology, frequency, and severity of seizures and the patient's age and previous history. Depression occurs in approximately 20% of patients, and the incidence of suicide is higher in epileptic patients than in the general population. Depression should be treated through counseling or medication. The selective serotonin reuptake inhibitors typically have no effect on seizures, while the tricyclic antidepressants may lower the seizure threshold. Anxiety can appear as a manifestation of a seizure, and anxious or psychotic behavior can sometimes be observed as part of a postictal delirium. Interictal psychosis is a rare phenomenon that typically occurs after a period of increased seizure frequency. There is usually a brief lucid interval lasting up to a week, followed by days to weeks of agitated, psychotic behavior. The psychosis will usually resolve spontaneously but may require treatment with antipsychotic or anxiolytic medications.

There is ongoing controversy as to whether some patients with epilepsy (especially temporal lobe epilepsy) have a stereotypical "interictal personality." The predominant view is that the unusual or abnormal personality traits observed in such patients are, in most cases, not due to epilepsy but result from an underlying structural brain lesion, the effects of antiepileptic drugs, or psychosocial factors.

Mortality of Epilepsy Patients with epilepsy have an increased risk of death that is roughly two to three times greater than what would be expected in a matched population without epilepsy. Most of the increased mortality is due to the underlying etiology of epilepsy, i.e., more widespread neurologic or systemic diseases in children and tumors or strokes in older adults. However, a small number of patients die from a syndrome known as sudden unexpected death in epileptic patients (SUDEP), which usually affects young people with convulsive seizures and tends to occur at night. The cause(s) remain unknown, although the leading theories propose brainstem-mediated effects of seizures on cardiac rhythms or pulmonary function.

Psychosocial Issues There continues to be a cultural stigma about epilepsy, although it is slowly declining in societies with effective health education programs. Because of this stigma, many patients with epilepsy harbor fears, such as the fear of becoming mentally retarded or dying during a seizure. These issues need to be carefully addressed by educating the patient about epilepsy and by ensuring that family members, teachers, fellow employees, and other associates are equally well informed.

Employment and Driving Many patients with epilepsy face difficulty in obtaining or maintaining employment, even when their seizures are well controlled. Federal and state legislation is designed to prevent employers from discriminating against patients with epilepsy, and patients should be encouraged to understand and claim their legal rights. Patients in these circumstances also benefit greatly from the assistance of health providers who act as strong patient advocates.

Loss of driving privileges is one of the most disruptive social consequences of epilepsy. Physicians should be very clear about local regulations concerning driving and epilepsy, since the laws vary considerably among states and countries. In all cases, it is the physician's responsibility to warn patients of the danger imposed on themselves and others while driving if their seizures are uncontrolled (unless the seizures are not associated with impairment of consciousness or motor control). In general, most states allow patients to drive after a seizure-free interval (on or off medications) between 3 months and 2 years.

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