Psychiatric manifestations in temporal lobe epilepsy: a controlled

study
GD Shukla, ON Srivastava, BC Katiyar, V Joshi and PK Mohan

The British Journal of Psychiatry 1979 135: 411-417

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Brit.J. Psychiat. (1979), 135,411—417

Psychiatric Manifestations in Temporal Lobe Epilepsy:

A Controlled Study
By G. D. SHUKLA, 0. N. SRIVASTAVA, B. C. KATIYAR, V. JOSH!
and P. K. MOHAN

SUMMARY Psychiatric disorder was studied in 62 patients with

temporal lobe epilepsy (study group) and 70 patients with grand mal
epilepsy (control group), both diagnosed electroencephalographically.
The two groups were similar as regards age, sex, socio-economic
status, duration and frequency of fits, family history and premorbid
personality.
A significantly greater number of temporal lobe epileptics had
emotional disturbances in childhood and psychiatric abnormalities
at the time of study. Neuroses, schizophrenia and behaviour disorder
occurred more commonly in the study group, while epileptic per
sonality and confusional psychosis were seen more frequently in the
controls.
The findings of the study are discussed in the light of relevant
literature.

Several authors have reported high incidence There have been very few controlled studies
of psychiatric symptoms in patients with epilepsy on the relativeincidenceof overallpsychiatric
(Pond, 1952; Keating, 1961; Nuffield,1961; morbidity in patients with temporal lobe
Kanaka etal,1967; Betts,1972; Bagadia etal, epilepsy (Guerrant et al, 1962; Small et al,
1973; and Abdul Gafoor and Santha Kumar, 1966; and Stevens, 1966). Most of the reports
1974). However, the controversy as to whether have eitherdescribedthe findingsforepileptics
or not the mental disturbance is related to the in general (Pond, 1952; Pond and Bidwell,
type of epilepsy persists. Thus, while some 1960; Agnihotri et al, 1972; and Bagadia et al,
workers (Rodin et al, 1957; Vislie and Hen 1973), or they have studied cases of temporal
rikson, 1958; Mirsky et al, 1960; Guerrant et al, lobe or psychomotor epilepsy only (Mulder and
1962; Small et al, 1962, 1966; Juul-Jensen, Daly, 1952; Bray, 1962; Virmany and Sawhney,
1964; Stevens, 1966, 1973; and Standage, 1973) 1966; Currie et a!, 1971; and Taylor, 1972) or
found no differences in the incidence of various else they have studied the relative frequency of
psychiatric abnormalities in different types of a particular psychiatric illness, mostly psychoses
epilepsy, others have reported a markedly (Slater a al, 1963; Flor-Henry, l969a, 1969b;
raised incidence of such abnormalities in and Bruens, 1971). Furthermore, the diagnostic
patients with temporal lobe epilepsy as com criteria used for epilepsy and psychiatric
pared to those with other types of the illness disturbances vary from author to author. It is
(Gibbs et al, 1948; Pond and Bidwell, 1960; therefore hardly surprising that the reported
Nuffield, 1961; Slater et al, 1963); Glaser, 1964; incidence of psychiatric symptoms also varies
Preston and Atack, 1964; Graham and Rutter, widely.
1968; Flor-Henry, l969a, l969b, 1972, 1974; The present communication is a report on a
and Bruens, 1971). comprehensive controlled psychiatric study on
411
 412 PSYCHIATRIC MANIFESTATIONS IN TEMPORAL LOBE EPILEPSY: A CONTROLLED STUDY
@ patients with temporal lobe epilepsy and deals —¿Echo-encephalography
when needed
with the psychiatric abnormalities in a group of —¿Carotid angiography 5
temporal lobe epilepsy patients compared with The history of epilepsy and psychiatric case
those found in a group of patients with epilepsy history were obtained from the patient and
of grand ma! type. from as many relatives as possible. These were
recorded on a schedule which was based on the
Material and Methods item-sheet published by Taylor and Falconer
The patients with temporal lobe epilepsy (1968) with certain modifications to suit the
attending the Epilepsy Clinic of the Institute of present study. A thorough psychiatric examin
Medical Sciences, Banaras Hindu University, ation was made according to the method given
during the period of one year formed the by Slater and Roth (1969). The psychiatric
sample for the study. Only those cases were evaluations of the cases were done by workers
included that had an unequivocal EEG (G.D.S. and O.N.S.) who were unaware of
evidence of temporal lobe epilepsy, either on their EEG classification.
routine or on potentiated recordings. The
criteria were: presence of spikes, sharp waves The psychiatric abnormalities were classified
and phase-reversals over the anterior or mid in accordance with the Diagnostic and Statistical
temporal areas (Ervin, 1967; and Driver, 1970). Manual—I! of the American Psychiatric Asso
Workers reporting on the EEG findings (P.K.M. ciation (1968). However, the DSM—II describes
and B.C.K.) were kept ‘¿blind'as regards the only two psychiatric entities in association with
clinical details of the patients. Cases with epilepsy, namely psychosis with epilepsy (code
neurological deficits and/or mental subnormality No. 293.2) and non-psychotic organic brain
were excluded. Thus, 62 cases coming under syndrome with epilepsy(code No. 309.4),which
observation during the period of study were are quite inadequate to classify and describe
included. the wide range of psychiatricdisordersasso
Seventy patients with epilepsy of grand ma! ciated with epilepsy. Therefore, in the present
type were taken as controls. These cases were study, the associated psychiatric disturbance
randomly selected from among the patients was diagnosed on the basis of the symptoms the
attending the same clinic during the period of patient exhibited, and he was given the diag
stud\. Here also, the diagnosis was based on nostic label which he would have received if he
EEG findings, i.e. paroxysmal bursts of high had not had a history of epilepsy. Certain
voltage polyspikes and irregular slow wave diagnostic groups which do not exist in the
activity occurring in a bilaterally synchronous DSM—II, viz, confusional psychosis (Dongier,
fashion (Solomon, 1967). The patients having 1960; Flor-Henry, l969a and b, 1972; and
neurological deficits and/or mental subnorm Bruens, 1971) and epileptic personality (Keat
ality were excluded. ing, 1961; Tizard, 1962; Treffert, 1964; and
The following investigations were employed Taylor, 1972) have also been used because of
in both the groups: their descriptive nature and because there are
1. Detailed history of epilepsy. no better terms to describe these conditions.
2. Detailed psychiatric case history. A thorough physical examination, including
3. Mental status examination and psychiatric neurological evaluation was carried out and
diagnosis. cases having neurological deficits were excluded.
4. Physical examination. All the patients were given treatment for
5. Laboratory investigations: epilepsy and, whenever needed, also for the
—¿Haemoglobin percentage, total and psychiatric condition. They were followed up at
differential leucocyte counts, ESR, intervals depending upon their clinical con
—¿Blood VDRL, dition. On every visit a psychiatric examination
—¿EEG:Routine and potentiated record was made to ascertain the relation of psychiatric
ings, symptoms to the frequency of epileptic fits.
—¿X-ray skull: AP and lateral views, The findings were tabulated and the data
 G. D. SHUKLA, 0. N. SRIVASTAVA, B. C. KATIYAR, V. JOSHI AND P. K. MOHAN 413
analysed statistically using Chi Square and and marital history and premorbid personality
Student's t-test for significance. (P >.05).

Observations Early emotional disturbances

The two groups were similar as regards age, A significantly greater number of patients in
sex, socio-economic status, education, duration the study group gave history of emotional
of epilepsy, frequency of fits, family, menstrual disturbances in childhood as compared to the
control group. One patient, a five year old boy
TABLE I presented with typical night terrors of two years
Early emotional disturbances in the two groups. (Percentage
figures in brackets) duration. He was found to have a right temporal
focus in the EEG.

lobe ma! Psychiatric disorders

epilepticsNNNil epilepticsGrand These have been given in Table II. There
DisturbancesTemporal
was a significant difference between the overall
incidence of psychiatric disorders in the two
(94) groups. About four-fifths of the patients of
Thumb sucking 3 (5) 1 (1) temporal lobe epilepsy manifested some psych
Nocturnal enuresis 5 (8) 1 (1) iatric disturbance as compared to about half
Night terrors/Nightmares 4 (6) 1 (1)
Nail biting51(82) of the cases in the control group.
(1)Total65@70= 2 (3)66 1
(a) ,JV'euroses:
Twenty-three patients (37 per cent) in the
4.7; df =1; P <0.05 study group as compared to eleven (16 per cent)
* One patient had three symptoms and another had in the control group, exhibited neurotic
two. symptoms. The commonest neurotic syndrome
TABLE II
Psychiatric disorders in the study and control groups. (Percentagefigure in brackets)

epilepticsNNNormal13(21)37(53)Neuroses epilepticsGrandma!
Psychiatric diagnosisTemporallobe

Anxiety neurosis
Hysterical neurosis
Depressive neurosis
Neurasthenic neurosis
2(16)Psychoses
Hypochondriacal
6
1 1
5 2
7 4
neurosis23(37) 4112

Schizophrenia 11
Confusional
4(10)Personality psychosis12(19) 173

disorders
Antisocial personality 1
Behaviour disorder 11 5
9(21)Total6270For
Epileptic personality14(23) 2151

differences between major categories x'= 16.89; df 3; P<0.001

414 PSYCHIATRIC MANIFESTATIONS IN TEMPORAL LOBE EPILEPSY: A CONTROLLED STUDY
was neurasthenic neurosis, followed by anxiety (f) Epileptic personality
neurosis, depressive neurosis and hypochondri There were 2 (3 per cent) such cases in the
acal neurosis. One patient each in the two groups study group and 9 (13 per cent) in the control
showed hysterical simulation of genuine fits group. The symptoms and signs in these patients
when under stress. formed a well defined constellation i.e. narrow
ing of field of interests, slowness of reaction,
(b) Schizophrenia: self-centredness, apathy, stubbornness, irrita
This condition was seen in 11 (17 per cent) bility, hypochondriasis, lability of mood, reli
cases of temporal lobe epilepsy as compared to giosity, circumstantiality, perseveration and
only 3 (4 per cent) of the control group. Almost querulousness. The patients were mostly in the
all the symptoms and signs of schizophrenia
were seen in these cases. The severity of schizo
phrenic symptomatology was directly related
second decade and had been having frequent
(almost daily)
average duration
fits over a long period,
being 8.1 years in the study
the I
to the frequency of fits in three patients, and 10.4 years in the control group.
inversely related in 4 patients and not related in
4 patients. The corresponding figures for the Discussion
control group were 2, 1 and 0 respectively. There seems to be a controversy over the
nomenclature, authors using the terms psycho
(c) Gonfusional psychosis: motor epilepsy and temporal lobe epilepsy
This diagnostic label has been used to interchangeably. Thus, Stevens (1966) studied
describe a state characterized by confusion, cases with psychomotor attacks even if there
clouding of consciousness, disorientation and was no EEG focus in the temporal lobe. On
bizarre behaviour. It was seen in one patient the other hand, Small et al (1966) included
(2 per cent) with temporal lobe epilepsy and in only those cases that had unequivocal EEG
4 (6 per cent) patients in the control group. In foci as well as classical clinical features of
all these cases the condition was precipitated by temporal lobe epilepsy. It is now well known
status epilepticus and was of short duration, that not all patients with temporal lobe focus
lasting 5—15days. in the EEG exhibit psychomotor seizures and
that not all cases with psychomotor seizures have
(d) Antisocial personality: a temporal lobe focus. In the present study,
One patient each in the two groups had therefore, both temporal lobe and grand ma!
features of antisocial personality disorder, i.e. epilepsy were diagnosed electroencephalo
frequent troubles with society, lack of guilt or graphically and the psychiatric symptoms were
shame, a tendency to blame others, stealing and recorded regardless of their degree of severity.
lying etc. The patient in the study group had The significantly greater incidence of early
made a suicidal attempt by taking five tablets of emotional disturbances in temporal lobe epi
Mandrax. Similarly, the patient in the control leptics agrees well with the findings of Aird et a!
group frequently intimidated and manipulated (1967) that unusual nocturnal phenomena
his relatives with suicidal threats. Both these occurred more frequently in patients with tem
patients had abnormal personalities before the poral lobe epilepsy than in the control group of
onset of seizures. normals. These phenomena are of interest in
view of the known activation of temporal lobe
(e) Behaviour disorder: epilepsy during sleep. Even more important
Eleven patients (18 per cent) in the study was the fact that these patients did not develop
group and 5 (7 per cent) in the control group, epilepsy until second decade. Thus, dysfunction
out of 16 and 17 cases respectively under the of the central nervous system may long ante
age of 15 years, exhibited symptoms of behaviour date the final development of overt seizures.
disorder. The commonest symptom was hyper The higher overallincidence of psychiatric
kinesis, followed by distractability, obstinacy morbidity in temporal lobe epileptics is in
and aggressive behaviour. contrast to the findings of Stevens (1966) and
 G. D. SHUKLA, 0. N. SRIVASTAVA, B. C. KATIYAR, V. JOSHI AND P. K. MOHAN 415
Small etal (1962, 1966) who failedto findany diagnosis. The severity of schizophrenic symp
such difference. This may be because of a toms had no definite relation with the frequency
difference in the diagnostic criteria used. For of fits.
This isin contrastto the observationsof
instance, Stevens used the single criterion of many (Ervinetal,1955; Reynolds, 1967, 1968;
admission to a mental institution or a psychiatric and Flor-Henry, 1969a and b) that there was an
facility, for diagnosing mental illness. This is inverse relation between the two. Our findings
rather too restrictive a criterion and she must agree with those of Small et al (1962), Slater
have missed many cases with relatively minor ci al (1963), Glaser (1964) and Standage (1973).
complaints. Our findings are similar to those of Behaviour disorders, with symptoms similar
Pond and Bidwell (1960), Flor-Henry (1969a to those commonly seen in brain injured
and b, 1972, 1974) and Bruens (1971). children, have been reported in epileptics by
Occurrence of neuroses in epilepsy is quite Bradley (1951) and Ounsted (1955). The
understandable and has been reported by former divided these symptoms into primary
several authors who attribute them to the and secondary ones. In the former, he grouped
unpredictability attached to epilepsy (Bingley, variability of mood, hyperkinesis and irritability
1958; Currie et al, 1971; and Bagadia et a!, etc. The secondary symptoms were protean and
1973). As in the present study, Taylor (1972) manifested as fear, resentment and despair.
found neuroses to be more common in temporal These might be considered to be the child's
lobe epilepsy. Similarly, Dongier (1960), reaction to his illness and appear to be specific
Dominion et al (1963) and Flor-Henry (1969a) to the child rather than to epilepsy.
found depression to be more common in these Two diagnosticgroups, i.e.epilepticper
patients. Furthermore, the simulation of genuine sonality and confusional psychosis were seen
fits by epileptics for secondary gains have been more commonly in the grand mal epileptics.
reported by Kesseler et al (1952), Betts (1972) This was in sharp contrast to the observations of
and Ramesh et al (1974). Liddell (1953) and Pond and Bidwell (1960)
Schizophrenia occurred more commonly in that personality change was more common in
patients with temporal lobe epilepsy. This temporal lobe epilepsy. Our findings are in line
observation is similar to those of Dongier (1960), with the conclusion of Juul-Jensen (1964) that
Slater et al (1963) and Bruens (1971). Dongier the personality changes in epileptics were
(1960) found the incidence of psychotic episodes related more to the severity of epilepsy than to
to be seven times greater in temporal lobe the location of the focus. As regards ‘¿confu
epilepsy as compared to other forms of epilepsy. sional psychosis', our findings were in total
Glaser (1964) concluded, ‘¿there
is little
doubt agreement with those of Dongier (1960),
that if epileptics with inter-ictal psychosis are Flor-Henry (1969a and b, 1972) and Bruens
studied the majority will be found to have (1971), in that the condition was precipitated in
psychomotor temporal lobe seizure states'. all the cases by status epilepticus, was char
Slateretal (1963),in theirseries
of69 caseswith acterizedby confusion,cluding of sensorium,
schizophrenia-like psychosis as well as epilepsy, disorientation and bizarre behaviour and occur
found that 65 per cent of the cases had temporal red more commonly in patients with generalized
lobe epilepsy. In his study of 19 epileptics with epilepsy.
psychotic symptoms, Bruens (1971) found that
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* G. D. Shukla, M.D., Lecturer in Psychiatry, M.L.B. Medical College,Jhansi (U.P.), India

0. N. Srivastava, M.D.,D.P.M.(Lond.),M.R.C.Psych.
(U.K.),Professor and Head of the Departmentof Psychiatry,
Institute of Medical Sciences, Banarns Hindu University, Varanasi (U.P.), India

B. C. Katiyar,M.D.. M.R.C.P.
(Lond.),
F.R.C.P.
(Edht.),
Professor
ofXeurology,
Institute
ofMedicalSciences,
Banaras
Hindu University, Varanasi (U.P.), India

V. Joshi, M.D..B 27/85, Durga Kund, Varanasi (U.P.), India

P. K. Mohan, M.D..
SeniorResident
inXeurology,
AllIndiaInstitute
ofMedicalSciences,
J'fewDelhi,India

* Reprints not available

(Received 30 October 1978; revised 2 April 1979)