Clinical picture and psychiatric aspects
From the perspective of the modern ICD-10 classification, epilepsy is assigned to the class of neurological disorders (category [G40]), which is why such patients are primarily managed by neurologists. However, in psychiatric practice, there is a serious classification problem: the current international system extremely inadequately represents specific psychiatric disorders that are inextricably linked with the course of epilepsy.
The clinical picture of the disease consists of several fundamental components. First, this is stereotyped paroxysmal symptomatology. Second, these are characteristic personality changes that steadily progress as the disease advances. And third, this is a possible outcome in the form of a specific defect — so-called concentric dementia.
Mental disorders in epilepsy are generally divided into three main groups:
- Paroxysms. These include twilight states of consciousness, various psychosensory seizures, and aura.
- Negative symptoms. Includes progressive personality changes and the development of dementia.
- Epileptic psychoses. Occur as independent clinical conditions within the course of the underlying disease.
Special attention in psychiatry is paid to personality changes. Patients are characterized by increasing egocentrism, the appearance of explosiveness, and torpidity — a pronounced slowing and rigidity of mental processes.
Evolution of views on the systematics of epilepsy
Throughout the history of medicine, prominent researchers have proposed various approaches to the systematization of epilepsy. As early as the 1st century AD, Claudius Galen proposed a basic division of the disease into two forms:
- Idiopathic (genuine) — that is, primary, true epileptic disease.
- Symptomatic (secondary) — arising against the background of organic brain and internal organ lesions (due to trauma, alcohol abuse, or psychogenic factors).
The modern view of Galen's concept has changed significantly. In the 20th century, scientists proved that the pathogenesis and EEG manifestations of all variants of epilepsy are practically identical, regardless of the root cause. Because of this, the scope of so-called "symptomatic epilepsy" was sharply narrowed. Today, this category includes only those paroxysms that have a fundamentally different origin, course, and prognosis (for example, in brain tumors, progressive paralysis, or Alzheimer's disease).
A significant contribution to the understanding of the disease was made by John H. Jackson (1835–1911). He not only detailed various variants of epileptiform paroxysms but also divided seizures into convulsive and non-convulsive. This division retains its relevance today, largely determining therapeutic tactics. At the same time, in practice, doctors often encounter a combination of various types of paroxysms in a single patient, as well as their transformation against the background of ongoing treatment.
Localization of foci and personality changes
Further development of epileptology is associated with the names of Wilder G. Penfield and Herbert Jasper. These researchers scientifically proved the direct link between epileptic symptoms and the presence of focal organic brain lesions (such as cysts, scar changes, and other defects). Based on their discoveries, they proposed dividing epilepsy into:
- Focal (also called local, partial, or lesional) — when a specific pathological focus can be identified (for example, temporal or diencephalic forms).
- Generalized (genuine) — when a clear lesion cannot be identified.
The psychiatric aspect of the disease was studied in depth by Jean-Pierre Falret and Emil Kraepelin. Falret was the first to describe specific personality changes and progressive epileptic defect. He made a crucial observation: such changes can develop in patients even in the complete absence of convulsive seizures. For such cases, he introduced the term "epilepsy without epilepsy".
In turn, Emil Kraepelin viewed personality changes as an obligate (i.e., strictly mandatory) primary symptom that often precedes the onset of the paroxysms themselves. However, modern psychiatry has adjusted this view: most contemporary epileptologists recognize personality changes as a typical, yet still not obligate (not mandatory) sign of this disease.
Briefly: answers to topical questions
What are the clinical signs of concentric dementia in epilepsy?
Clinical signs of concentric dementia in epilepsy include specific changes in memory, thinking, speech, and personality.
- Memory — selective in nature (practically relevant information is remembered better).
- Thinking — characterized by pathological viscosity, rigidity, increasing circumstantiality, and loss of the ability for abstract thinking.
- Speech — characterized by oligophasia (a sharp decrease in vocabulary), multiple repetitions, and excessive use of diminutive suffixes.
- Personality and emotions — pronounced egocentrism, pedantry, pettiness, despotism toward loved ones, and obsequiousness toward superiors.
- Comprehension — abstract concepts are not comprehended, but the general assessment of the situation remains correct with reduced insight into the illness.
What types of epileptic auras are distinguished in clinical psychiatry?
In clinical psychiatry, several types of epileptic auras are distinguished, indicating the localization of the pathological focus.
- Somatomotor — indicates a lesion of the posterior central gyrus.
- Olfactory — indicates localization in the uncinate gyrus.
- Visual — associated with damage to the occipital lobes.
Also, based on clinical manifestations, auras can represent separate motor acts, complex actions, sharp mood swings, sensory or ideational phenomena (hallucinations, visceral sensations, surges or stopping of thoughts).
What clinical forms are epileptic psychoses divided into?
Epileptic psychoses are divided into acute and chronic forms.
- Acute psychoses — include twilight clouding of consciousness (accompanied by agitation, delusions, hallucinations, aggression followed by complete amnesia) and paroxysmal psychoses with preserved memory (manifested by fantastic oneiric experiences, unsystematized persecutory delusions, illusions, and psychic automatism).
- Chronic psychoses — occur rarely; their clinical picture is dominated by everyday delusions, less frequently observed religious delusions or delusions of control.
What specific graphoelements are recorded on the EEG in epilepsy?
In epileptiform activity on the EEG, the following may be recorded:
- Spikes — single and multiple.
- Sharp waves — with a duration of 70–200 ms and an amplitude of more than 50 µV.
- Spike–slow wave complexes ("spike-wave") — with a duration of 160–250 ms; during an absence seizure, a "spike-slow wave" complex is recorded.
- Sharp–slow wave complexes — with a duration of 500–3000 ms.
- Short-term bursts of high-amplitude slow waves.
Epileptiform changes on the EEG can also be recorded in people without clinical signs of epilepsy.
The ETV triad of personality changes in epilepsy: ETV: Egocentrism, Torpidity (slowness), Violent explosiveness.
Class and exam questions
Is a change in personality inevitable for a patient with epilepsy?
No, not necessarily. Although Emil Kraepelin considered personality changes to be an obligate (mandatory) symptom, modern specialists view them as a typical, but not strictly mandatory sign of the disease.
What does the term "epilepsy without epilepsy" mean?
This concept was introduced by Jean-Pierre Falret to describe a form of the disease in which the patient lacks typical convulsive paroxysms, yet develops characteristic personality changes and a progressive epileptic defect.
Why has the concept of symptomatic epilepsy been narrowed in modern medicine?
In the 20th century, pathogenetic similarity and identical EEG patterns were demonstrated for most forms of epilepsy, regardless of the cause. Currently, only those paroxysms that have a fundamentally different prognosis and origin (e.g., in tumors or Alzheimer's disease) are classified as symptomatic.
What is the value of Jackson's seizure classification today?
The division of seizures into convulsive and non-convulsive, proposed by John H. Jackson, still determines therapeutic tactics, despite the fact that patients often present with a mixed clinical picture and symptom transformation during treatment.
What else to study on this topic
- Twilight states of consciousness as a form of paroxysms
- Psychosensory seizures and aura characteristics
- Mechanisms of concentric dementia development
- Clinical presentation of standalone epileptic psychoses
Master the entire topic in the "Psychiatry" course
This is a summary. The course covers everything tested in classes and exams.
- Complete study guide on "Epilepsy" and 499 more pages of the subject
- Assignments and quizzes after every topic — just like in a colloquium
- AI tutor answers questions on the topic anytime
- 7 video lessons on the subject
Other topics in "Chapter 20. Epilepsy"
Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.