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In this chapter, we review the current state of knowledge regarding the various areas of overlap between the fields of epilepsy and psychiatry. After a brief discussion of the phenomenology, pathophysiology, and clinical approach to epilepsy in general, we discuss the various psychiatric and cognitive manifestations of epilepsy. Neuropsychiatric symptomatology in epilepsy can be broadly divided between peri-ictal symptoms and interictal symptoms. The former bear a direct temporal relationship to seizures while the latter do not. Lastly, we discuss the neuropsychiatric impact of epilepsy treatments and the special considerations necessary for psychopharmacological management in patients with epilepsy (PWE).
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A relationship between epilepsy and mental illness has been recognized since ancient times. The Hippocratic school in ancient Greece, who preferred natural explanations for disease over the supernatural ideas of the day, recognized the importance of the brain as a mediator of cognition and emotion, and of mental illness and epilepsy. A direct relationship between epilepsy and mental illness was also recognized, as evidenced by the Hippocratic statement that “Most melancholics usually also become epileptics, and epileptics melancholics. One or the other prevails according to where the disease leans: if toward the body, they become epileptics, if toward reason, melancholics.”1 Supernatural conceptions of epilepsy and mental illness were prevalent in ancient times, particularly among the nonmedical public, and ancient writers often failed to recognize a clear distinction between epilepsy and mental illness. This is exemplified by the concept of lunacy and the word “lunatic,” colloquially (and pejoratively) used in modern English to refer to an individual with mental illness. The term derives from the Latin word “lunaticus” that likely referred initially to an individual with epilepsy, as can be seen by its usage in the Vulgate, the 5th-century Latin translation of the Bible, to refer to the epileptic child healed by Jesus (Matthew 17:15). While the Biblical perspective on epilepsy and mental illness is that both relate to demonic possession, both the Latin and original Greek versions of the word contain a prefix relating to the moon (“luna-” and “selen-,” respectively), likely reflecting a notion during Roman times that the cyclical attacks characteristic of epilepsy are related to the cycles of the moon.
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Christian views on the role of demonic possession became increasingly prominent during the Middle Ages, although the medical writers dissociated themselves from these views, often favoring natural explanations. However, an etiological role for cycles of the moon via natural mechanisms was considered by physicians in a manner akin to that in which the cycles of the moon affects the tides. The periodicity of symptomatology seen in bipolar disorder may have lent support to the lunar theory of mental illness. Because mental illness and epilepsy were considered mechanistically similar, there may have been little incentive to separate them nosologically, and the term “lunacy” came to refer to both conditions, ...