Anxiety

Anxiety disorders and individual symptoms of anxiety are commonly identified in people with epilepsy. During the ictal phase, panic and fear are the most frequent psychiatric symptoms presenting as an expression of seizure activity. Often ictal fear or panic can be misdiagnosed as a panic disorder, as both types of episodes can produce similar symptoms, such as palpitations, shortness of breath, clammy hands, or pallor or flushing of the face.

To avoid an erroneous diagnosis and treatment, it is essential to distinguish between ictal panic and panic attacks. The following are the principal differences between these two types of events:

Ictal panicPanic attack
Very short duration (< 30 seconds). Duration usually several minutes.
Intense fear or sensation of doom unlikely. Intense fear, sensation of "impending doom."
Fear usually followed by loss of awareness of surroundings, automatisms; no memory of this period. Intense sensation of doom may prevent detailed awareness of surroundings.
Person not responsive to other people while awareness is lost. Person remains responsive to other people.

Patients are also likely to experience symptoms of anxiety during the postictal period. These symptoms include panicky feelings, constant worry, and fear of leaving the house or being left alone. In the study of postictal psychiatric symptoms mentioned above, 45 of 100 consecutive patients with poorly controlled partial epilepsies experienced symptoms of anxiety after more than half of their seizures. The average duration was 24 hours, with a range of several minutes to several days. Postictal symptoms of anxiety occurred together with symptoms of depression and disturbances of sleep and appetite.

Interictal anxiety disorders are relatively frequent and are more prevalent in people with epilepsy than in other people. They can be identical to those identified in people without epilepsy, and include panic disorders, generalized anxiety disorders, and phobias, including agoraphobia and social phobia.

Interictal anxiety disorders result from a variety of factors often acting together. These factors include:

  • the neurochemical and electrophysiologic changes associated with the seizure disorder (usually affecting the temporal and frontal lobes)
  • a reactive process to adverse situations
  • antiepileptic drugs

The management of interictal anxiety disorders is similar to the management of idiopathic anxiety. Besides AEDs, the clinician may prescribe anxiolytic and antidepressant medications or behavioral therapy.

Dissociative experiences

Dissociative experiences, in which the patient's sense of identity and memory are disturbed, are another important class of symptoms that may develop during a partial seizure. Dissociative symptoms include depersonalization, derealization, autoscopy (looking at one's body from outside), and multiple personalities. These symptoms tend to be limited to peri-ictal periods.

Adapted from: Holzer JC and Bear DM. Psychiatric considerations in patients with epilepsy. In: Schachter SC, Schomer DL, eds. The comprehensive evaluation and treatment of epilepsy. San Diego, CA: Academic Press; 1997. p. 131-148.
With permission from Elsevier (www.elsevier.com)

Authored By: 
Jacob C. Holzer MD
David M. Bear MD
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Reviewed By: 
Andres M. Kanner MD
on: 
Thursday, April 1, 2004