Appropriate psychiatric interventions depend on a thorough diagnostic evaluation of the patient. As stressed earlier, psychiatric and behavioral problems in epilepsy may result from a variety of factors, which need to be identified before appropriate treatment can be given. Symptoms may be the result of an underlying medical condition that is causing both seizures and psychiatric disturbance; toxic-metabolic effects of medications or other substances; personal, social, or familial factors related or unrelated to the epilepsy; or the location of the seizure focus and the effect of the seizure activity, which may be producing the peri-ictal and interictal disturbances already reviewed. Identifying which factors may be operational in a patient with epilepsy is critical.
Psychotherapy (in one of the many forms available) may be an appropriate treatment intervention for some patients with identified problems, such as conflicts, adjustment problems, losses, emotionally traumatic experiences in the past, and persistent functional difficulties (e.g., in social or work situations). This modality is not appropriate as primary treatment for ictal symptoms (e.g., prolonged postictal depression) or interictal behavioral changes.
Behavioral therapy entails developing a strategy aimed at reducing or changing an unwanted symptom or behavior. It works well for some psychiatric conditions (such as obsessive—compulsive disorder) but is not appropriate for others (such as psychotic symptoms in acute schizophrenia). Behavioral therapy requires a significant amount of motivation on the part of the patient. Its use in patients with epilepsy depends on identifying specific behaviors or problems that might be reduced behaviorally.
Electroconvulsive therapy (ECT) is a well-accepted treatment for major depression, usually when the symptoms are refractory to medications. One contraindication to ECT is increased intracranial pressure. In patients with epilepsy, ECT may be an appropriate treatment intervention for refractory depression or mania. One effect of ECT is a temporary increase in the seizure threshold, which commonly results in the need for a higher stimulus intensity during the course of ECT.
A complicating factor in the epileptic patient is the need to reduce antiepileptic medication blood levels during the course of ECT, with the risk of exacerbating the underlying seizure disorder. Despite this, ECT can be a useful treatment modality in some patients with severe psychiatric symptoms refractory to other treatments.
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