Epilepsy: types, symptoms and the role of the psychologist

Based on historians Cantilino and Carvalho (2001), if we look at the history of humanity, we will see that initially epilepsy indicated something like “demonic possession” or “accumulation of evil humors”. Some scholars such as Hippocrates (460 to 377 BC) and Galen (131 AD), already had a view that epilepsy would be a disease of brain origin. However, only in the 18th century was the first treatise on epilepsy written and masturbation was still attributed as the cause of the crisis.

Arriving in the 19th century, Kraepelin believed that epileptic patients had personality changes with a disposition to psychosis. From then on, new scholars and research on epileptic patients emerged.

However, despite these discoveries, the patients continued to present their crises and a significant number of them evolved with some type of psychiatric disorder. For this reason, studies are currently being developed on the neurological and psychiatric aspects of epilepsy and a theoretical-practical integration between the two specialties.

What is Epilepsy?

Epilepsy is the most common neurological disease in the general population. According to Ballone (2005) “the term Epilepsy refers to a chronic condition of periodic or repeated attacks, caused by a pathophysiological condition of brain function, resulting from the spontaneous and excessive discharge of cortical neurons. However, one should not understand epilepsy as an exclusively convulsive disease. Convulsion is just one of the symptoms of the disease, which translates the occasional existence of an excessive and disordered discharge of the nervous tissue on the muscles of the organism. Epilepsy, however, must currently be conceptualized as a syndrome with a set of signs and symptoms resulting from this paroxysmal cerebral dysrhythmia. In this syndrome, therefore, the seizure itself may even be absent, as is believed to happen in most dysrhythmic patients.”

One of the main concerns for psychiatrists involving this pathology is the consideration of a diagnosis of epilepsy in psychiatric patients, in which 30% to 50% of epileptics have psychiatric difficulties at some point during the course of the illness (Kaplan, 1997).

In summary, we can say that epilepsy would be a temporary alteration in the functioning of the brain (not obtained through drugs, fever or metabolic disorders), which then produces motor, sensitive, sensorial and psychic/neurovegetative manifestations (paroxysmal cerebral dysrhythmia). This change can last for a few seconds or minutes, and with that the brain sends out incorrect signals. Can be:

Partial: these are seizures characterized by focal discharges, originating from a portion of a cerebral hemisphere, with lowering of consciousness and widespread: reach the two cerebral hemispheres.

According to Shorvon (2011) there are four types of definition for Epilepsy:

1. Idiopathic epilepsy – defined as an epilepsy of predominantly or presumably genetic origin and in which there is no major neuroanatomical or neuropathological anomaly. This includes epilepsies with a presumably multigenic or complex heredity, although the genetic basis is currently unclear.

2. Symptomatic epilepsy – defined as epilepsy of acquired or genetic cause, associated with major anatomical or pathological anomalies and/or clinical facts indicative of an underlying disease or condition. We therefore include developmental and congenital disorders in this category when they are associated with pathological changes, whether of genetic or acquired (or even cryptogenic) origin.

3. Provoked epilepsy – defined as an epilepsy in which a specific environmental or systemic factor is the predominant cause of seizures and in which there are no major neuroanatomical or neuropathological anomalies. Some “provoked epilepsies” will have a genetic basis and some will have an acquired basis, but in most an innate cause cannot be identified. Reflex epilepsies are included in this category (being usually genetic) as well as epilepsies with a notorious seizure precipitant.

4. Cryptogenic epilepsy – defined as an epilepsy of a presumably symptomatic nature in which the cause has not been identified. The number of such cases is decreasing, but today it is still an important category, accounting for at least 40% of adult-onset epilepsy cases.

Classification and Diagnosis of Epilepsy

We must consider epilepsy from two points of view: firstly, as a syndromic set of psychological signs and symptoms and, secondly, as a possibility of manifestation of epileptic potentiality in the form of defined clinical crises, from the classic generalized seizure to minor sensory symptoms, cognitive or psychomotor.

In the case of approaching the syndromic set of the dysrhythmic patient, it is necessary to understand the epileptic, with his way of being and his personality. In the case of clinical characterization of seizures, an attempt is made to understand epilepsy, with its clinical picture, course and evolution. Psychiatry is interested in approaching the epileptic in general and epilepsies with a peculiar psychic expression. The other forms are better studied by neurology.

Epilepsies can be partial or generalized. The so-called Partial epilepsies are those that affect only one of the cerebral hemispheres. Among them, Simple Partials will be considered whenever there is no impairment of consciousness and, on the contrary, Complex Partials if there is such impairment. Generalized epilepsies that affect both cerebral hemispheres and, like the partial ones, can be Convulsive and non-Convulsive.

I – PARTIAL EPILEPSY
Simple
complex
II – GENERALIZED EPILEPSY
convulsive
Non-convulsive

Among the epileptic seizures, of particular interest to psychiatry, the Partial Seizures with Psychic Symptomatology. These crises can manifest themselves in the form of paroxysmal language disorders with transient aphasia crises, they can present paroxysmal memory lapses, sensations of “déjà vu”. Not infrequently, there are complaints of distortions in the perception of objects, sometimes perceived as enlarged, sometimes as diminished, misshapen, changed position, etc.

Other peculiarities may be present in Partial Seizures with Psychic Symptomatology, such as, for example, paroxysmal changes in mood and affection, feelings of pleasure and displeasure, sudden and unmotivated episodes of depression and anger, of fear and terror. The beginning and end of these manifestations is, as a rule, abrupt and, frequently, there are other signs suggestive of concomitant dysrhythmia.

It is of paramount importance for the clinician to be aware of these perceptual and emotional changes resulting from epilepsy. These are situations that arouse, in most psychiatrists, a great inclination to use antipsychotics and/or antidepressants but which, nevertheless, respond much better to the use of anticonvulsants, notably carbamazepine.

When these Partial Seizures are Complex, changes in consciousness can take the form of a narrowing, called the Twilight State, often of medium or long duration. In these Twilight States, a certain motor automatism is common, almost always with attitudes without a practical objective and a facial expression suggestive of fear or aggressiveness. If there is extreme aggressiveness during the Twilight State, we can speak of Epileptic Furor, a disorder responsible for serious social and family damage. After the episode, usually the patient does not keep a clear memory of what happened.

Psychiatrically, however, we are interested in individuals not only with electroencephalographically or pathophysiologically delimited seizures but, above all, those with a broader set of signs and symptoms capable of giving them a peculiar way of contacting reality and living. According to this concept, many authors have used the term Epileptic Personality (9,10), Epileptiform or Epileptoid to designate this constellation of psychic characteristics associated with dysrhythmic activity of the Central Nervous System, notably the temporal lobe.

The role of the psychologist

It is essential that people know what epilepsy is, what are its practical implications, so that the patient and his family are no longer victims of prejudice and stigma in the community. Therefore, this work aims to show the importance of working in groups in epilepsy, providing basic guidelines on how to carry them out. Working with groups facilitates interpersonal relationships and focuses on treating problems and difficulties, especially in chronic illnesses. From a psychological point of view, it provides an opportunity to exchange experiences and experiences, in addition to enabling interaction between patients and health professionals. The groups aim to help in the knowledge of information, discuss fears, anxiety and confusion regarding epilepsy, being an opportunity to share ideas, express feelings and exchange experiences with other people who live similar situations. In addition, people can increase their knowledge, discuss sorrows and discomforts related to epilepsy Patients with epilepsy present social isolation, difficulty in social relationships, at work, at school, at leisure and even in activities of daily living. Therefore, it is often said that epilepsy is a condition that affects the biopsychosocial well-being, that is, it affects the patient’s life as a whole.

Bibliographic references

Ballone GJ – Epilepsy, Aggressiveness and Personality – in. PsiqWeb, Internet, available at www.psiqweb.med.br, revised in 2005.

CANTILINO, A.; CARVALHO, JA Psychoses related to epilepsy: a theoretical study. Revista Neurobiologia 64 (3-4): 109-16, 2001.

CID-10. ICD-10 Classification of Mental and Behavioral Disorders. Medical Arts, Porto Alegre, 1993.

DSM-IV-TR. Diagnostic and Statistical Manual of Mental Disorders. 4 ed. Medical Arts, Porto Alegre, 2002.

HARRISON, J. Internal Medicine. 13th ed. McGraw Hill International, Philadelphia, 1994.

JASPERS, K. ​​General Psychopathology. Atheneu Bookstore, 1973.

KAPLAN, I.; SANDOCK, BJ Compendium of Psychiatry. Medical Arts, Porto Alegre, 1997.

SCHNEIDER, K. Clinical Psychopathology. 3 ed. Mestre Jou, São Paulo, 1978.

Simon D. Shorvon. Etiological classification of epilepsy. Epilepsia, 52(6):1052–1057, 2011. UCL Institute of Neurology, University College London, Queen Square, London, United Kingdom. Available from: http://onlinelibrary.wiley.com/doi/10.1111/j.1528-1167.2011.03041.x/pdf

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