Elsevier

Epilepsy & Behavior

Volume 7, Issue 2, September 2005, Pages 161-171
Epilepsy & Behavior

Review
Anxiety in patients with epilepsy: Systematic review and suggestions for clinical management

https://doi.org/10.1016/j.yebeh.2005.05.014Get rights and content

Abstract

Up to 50 or 60% of patients with chronic epilepsy have various mood disorders including depression and anxiety. Whereas the relationship between epilepsy and depression has received much attention, less is known about anxiety disorders. It is now recognized that anxiety can have a profound influence on the quality of life of patients with epilepsy. The relationship between anxiety disorders and epilepsy is complex. It is necessary to distinguish between different manifestations of anxiety disorder: ictal, postictal, and interictal anxiety. Preexisting vulnerability factors, neurobiological factors, iatrogenic influences (antiepileptic drugs, epilepsy surgery), and psychosocial factors are all likely to play a role, but with considerable individual differences. Despite the high prevalence of anxiety disorders in patients with epilepsy, there are no systematic treatment studies or evidence-based guidelines for best treatment practice. Nevertheless, a practical approach based on the temporal relationship between anxiety and epileptic seizures allows clinicians to consider appropriate treatment strategies to reduce the psychiatric comorbidity in patients with epilepsy.

Introduction

Psychiatric aspects of epilepsy have been extensively reviewed in the past [1], [2], [3], [4], [5], [6], [7]. Several large studies have shown that the rate of mood disorder is higher in patients with epilepsy than in those with other chronic medical conditions such as diabetes and asthma [8]. Most of the attention has been focused on depression, despite the fact that anxiety may actually be more common and equally disabling [6], [9], [10], [11]. As early as 1971, Currie and colleagues documented a 19% point prevalence of anxiety disorder, compared with an 11% point prevalence of depressive disorder, in patients with temporal lobe epilepsy [12]. A more recent study looking for psychopathology using a standardized diagnostic interview in inpatients with all types of epilepsy obtained similar results: The 1-year prevalence of anxiety disorders was 25%, and that of mood disorders, 19% [13]. However, in some secondary care and specialist settings, the prevalence of anxiety disorder may exceed 50% [9], [14].

Several recent studies have attempted to examine the relative contribution of anxiety symptoms to reduced health-related quality of life (HRQOL) in patients with epilepsy. In a study from Korea, anxiety was the most significant predictor of reduced HRQOL, explaining 27% of the variance compared with 12% for depression and 3% for seizure frequency [15]. Johnson and colleagues also examined the relative contribution of depression and anxiety to HRQOL in patients with temporal lobe epilepsy [16]. Depression and anxiety were independently associated with reduced HRQOL, and psychiatric comorbidity explained more variance in HRQOL than did combined groups of clinical seizure or demographic variables.

Section snippets

Epidemiology and phenomenology of anxiety syndromes in epilepsy

The DSM-IV [17] distinguishes between 11 different types of anxiety disorder, but most are excluded when a significant explanatory medical condition is present. No groups have attempted to delineate the special features (if any) of anxiety occurring in epilepsy, an approach that has been successful in depression [18]. It is therefore unclear if current diagnostic instruments for anxiety perform adequately in this population. In addition, most studies have not considered subtypes of anxiety

Risk factors for anxiety

Seizure frequency has been linked with severity of anxiety in some [33] but not all studies [15]. This does not necessary imply ictal fear, but rather that as the burden of epilepsy increases, so does the anxiety. Yet clinically, the degree of anxiety is dissociated from seizure frequency in that it is the individual’s perception of danger (e.g., of falling or dying) that is critical. Age and gender have a relatively subtle effect: for example, first-onset epilepsy in late life may be linked

Clinical differential diagnosis

It is useful to distinguish between epilepsy-related ictal, postictal, and interictal anxiety symptoms and “comorbid anxiety” unrelated to epilepsy:

  • Anxiety as an ictal phenomenon (for instance, as an isolated aura or simple partial seizure causing the patient to experience fear/panic, especially from temporal lobe epilepsy with involvement of the amygdala)

  • Anxiety as a postictal phenomenon (for instance, soon after recovery from a fit, often in association with clouding of consciousness or

Anxiety symptoms and epilepsy surgery

The prevalence of anxiety disorders in candidates for epilepsy surgery has been reported to be between 10 and 30% [76], [77]. Most studies suggest that if surgery for epilepsy is successful, then quality of life is improved [78]. This is usually reflected in an improvement in mood, but some patients develop new-onset mood disorders [79]. Anxiety may persist in the first year after surgery, despite an improvement in depression [80], [81]. However, in the long term, anxiety levels generally

Anxiety symptoms and antiepileptic drugs

There is a complex relationship between anxiety symptoms and the medical therapy of epilepsy (see Table 2). Antiepileptic drugs (AEDs) can exacerbate anxiety or have beneficial mood-stabilizing and anxiolytic effects. Several AEDs (valproate, tiagabine, gabapentin, and pregabalin) have been used in trials for the treatment of anxiety disorders with variable success [59], [60], [61], [62], [63], [64], [65]. It remains unclear why some AEDs increase anxiety in some patients with epilepsy. There

Basic information and support

An essential component of treatment for any patient and his or her carer(s) must include an adequate explanation of the condition, pointers to further information, and provision of further support [89], [90]. The degree of information requested will vary considerably between patients. One reason for the need to consider this as mandatory is that perceived needs are often underestimated by staff [91]. The role of several of these elements, particularly “psychoeducation,” is finally being

Conclusion

The prevalence of anxiety symptoms is higher in patients with epilepsy than in the general population or in patients with several chronic medical disorders, suggesting a special relationship. Detailed descriptions of the prevalence of anxiety disorders in patients with well-controlled epilepsy versus treatment-refractory epilepsy or those with a history of status epilepticus are not currently available. The psychopathology of anxiety occurring in different phases of epilepsy is beginning to be

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