Patients who have epilepsy have a lot to manage personally. Temporal Lobe Epilepsy (TLE) is the most frequently occurring type of epilepsy, with these patients at the greatest risk of developing mental health issues. There are reasons for this, which we will explore in this article, and we will go through some measures that you and your loved ones can take to manage your well-being. 

Introduction

What is temporal lobe epilepsy?

Epilepsy is a widespread condition affecting the brains and nervous systems of millions worldwide. Epilepsy patients have multiple seizures during which they move involuntarily with sudden bursts of electrical signalling within the brain. This can occur in any brain region, with the temporal lobe being the most frequent site.¹ Epilepsy occurring in a specific brain region is called focal epilepsy.²

The 2 key seizure types in TLE are:

• Focal aware seizures: These are often called “auras”.¹ Patients may taste, smell or hear things that are not there in that moment with them. Additionally, they may have a sudden sense of fear and visceral-related physical symptoms (like a sick feeling in the stomach)¹
• Focal impaired awareness seizures: Consciousness may be lost as a focal aware seizure progresses towards a focal impaired awareness seizure.¹ Patients gradually lose awareness and motion, with their pupils dilating

We have another article on Klarity about TLE, with a section on “psychosocial impact”, which we will explore further.

Comorbid conditions

Comorbidities refer to conditions that can occur alongside each other. When exploring the relationship between TLE and psychiatric conditions, we need to understand the periods before, during and after seizure occurrence, in which mental symptoms can present themselves.³ These stages are as follows:⁴

• Pre-ictal (prior to seizures)
• Ictal (during the seizure)
• Postictal (after the seizure)
• Interictal (between seizures) 

Due to symptom overlap between mental health issues and ictal symptoms, it may be difficult to identify TLE and psychiatric conditions as co-occurring disorders. As a result, the patient themselves may not be able to express how they feel. Even if seizure medications are optimised, their overlooked mental health difficulties may worsen, negatively impacting quality of life.³

How does temporal lobe epilepsy affect our mental health? 

The temporal lobe, located in the lateral part of the brain, across both hemispheres, has a significant role in our understanding of speech and language, our emotions and how we navigate them, and the things we see around us. It is also involved in visual memory retention.

The occurrence of mental health issues amongst patients with TLE is due to the temporal lobe’s importance in emotion and behaviour regulation, with the hippocampus and the amygdala being key structures involved in this process.² Hippocampal Sclerosis (HS) is deemed a frequent instigator of heightened emotional struggles in TLE patients.⁴ However, there are other possible triggers of cognitive impairment in TLE, which contribute to the development of mental health difficulties. 

Recurrent seizures can lead to worsened nerve damage, which may affect the transmission of brain chemicals called neurotransmitters; some of these have a role in stabilising our mood, with serotonin being a key example.⁴ Despite this area requiring further research, mutations in genes corresponding to ion channels within the brain’s nerve networks may be underlying the continual hyperexcitability that exacerbates nerve damage.⁴ This, in turn, diminishes the brain’s capacity to compute surrounding objects, with patients at risk of becoming increasingly disoriented.⁴

What are the key mental health issues amongst those with temporal lobe epilepsy (TLE)?

Depression and anxiety: underlying anatomy and surface presentation 

Depression and anxiety have historically been key comorbidities in TLE patients. We can connect anatomical changes within the medial temporal lobe to establish underlying pathological events for the development of these distinctly related conditions. 

The hippocampus and amygdala are both involved in emotion control. Damage to the hippocampus (commonly seen in TLE) can hinder our ability to process our emotions; when we cannot work out why we are experiencing these feelings, we are at risk of becoming more depressed.⁴

There is also a connection between structural changes to the amygdala or other areas in the medial temporal lobe and anxiety development. Furthermore, HS is associated with a greater likelihood of seizure anticipation anxiety in TLE patients. 

Within these patients, several different types of depression can occur:⁴

• Major Depressive Disorder: Patients may become persistently sad, with less pleasure in doing activities they would normally enjoy and in eating their favourite foods. Their sleep may also become disturbed, and they may feel more suicidal
• Dysthymic disorder: Patients have more chronic periods of depressive symptom
• Bipolar disorder: Categorised by periods of mania and depression
• Minor depression: Periods of depression that are shorter and less frequent than MDD

Anxiety symptoms in TLE patients may be pre-ictal, ictal, post-ictal or interictal⁴. However, anxiety can be triggered by medical treatments for epilepsy as well. 

Epilepsy is thought to be bidirectionally linked with both depression and anxiety; persistent stress is a known seizure trigger, and the anticipation and sensation of seizures can cause fear in patients.⁴ 

Psychosis 

Although rare, psychosis is a critical comorbidity to treat if it affects a patient; it too can be categorised as “preictal, ictal, postictal” or “interictal”⁵. In psychosis, patients may lose touch of their environment, becoming immersed in beliefs with no truth to them (delusions), or hearing sounds and seeing things that are not physically present (hallucinations). 

• Preictal Psychosis: Patients experiencing this psychosis subtype may become dissociated from their surroundings, and experience deja vu⁵It rarely occurs in comparison to the other categories of psychosis in TLE patients
• Ictal Psychosis: Patients may hear voices or see visuals evoking fear and paranoia within them. It is strongly recommended that antipsychotics (the medication commonly indicated for psychosis) are not used to treat this subtype^5,6
• Postictal Psychosis: Mood changes and grandiose delusions (which make people believe they have special identities or powers) are seen in these patients. 
• Interictal Psychosis: There are 2 subtypes:⁵
  • Brief Interictal Psychosis: Occurs between moments of increased seizure frequency
  • Chronic Interictal Psychosis: Episodes do not occur in relation to seizure frequency  

There is currently a lack of available evidence concerning how these clinical presentations could be effectively assessed and treated. However, it has been emphasised that psychiatrists and neurologists should always consider the possibility of psychosis in epilepsy patients.⁵

Post-traumatic stress disorder (PTSD) 

In an individual suffering from PTSD, the patient may have certain triggers causing them to relive a distressing event or have intrusive thoughts in relation to the event. As a result, they may actively try to avoid these triggers, becoming hyper-aware of their surroundings, and having subsequent mood swings and thought process disturbances.⁶

The general relationship between PTSD and epilepsy has historically been under-explored, but in a recent analysis of studies, around a fifth of the sample had coexisting PTSD and epilepsy. Even more crucially, epileptic patients are three times more likely to develop PTSD when compared with healthy counterparts. However, with individual study population sizes being minimal in research analysis so far, more work will need to be done to acquire further evidence. Nevertheless, as traumatic experiences are becoming more frequent amongst epileptic patients, the relationship between PTSD and epilepsy (including TLE) must be further explored.⁶  

How can you manage mental health when things get tough

Who should I talk to first? 

Consulting your doctor (GP or neurologist) is the first step. Prior to proceeding further with treatment, a thorough history is needed to gain a bigger clinical picture of your medical history, brain functioning, emotional control and ability to cope with daily activities. MRI scan referral is a key recommendation for those with suspected HS.⁷

What medications can I consider?

With the effects of Anti-Seizure Medications (ASMs) on patient cognition well documented, regular review of a patient’s prescribed drugs is also important as they progress with epilepsy treatment⁷. Though there are prescription drugs that can be considered for co-existing mental health issues, care needs to be taken in determining which medication to use, if any. 

Some antipsychotics (e.g. chlorpromazine and clozapine) reduce seizure threshold, which means that seizures are more likely to occur in patients treated with these medications. Meanwhile, Risperidone is the least likely antipsychotic to increase the likelihood of seizures according to recent studies; this means that it is generally the recommended drug for psychosis in epilepsy, if required. However, further research will be needed.⁵ Due to the overlap between psychotic and seizure symptoms, you must advocate for yourself and your experiences as much as possible; this can help clinicians to incorporate your viewpoints into their decision-making process. 

Contrastingly, Selective Serotonin Reuptake Inhibitors (SSRIs) are reported to have the opposite effect of antipsychotics, by reducing the chances of seizure events whilst simultaneously improving mood. SSRIs are usually prescribed for depression and anxiety. If offered an SSRI, sticking to a regular dose regimen is important due to the impact on levels of serotonin.⁷

In situations where SSRIs are found to have a partial effect or no impact, your treatment team will likely check how regularly you have been taking doses before considering further treatments; some other non-SSRI antidepressants (such as SNRIs, NASSAs, or tricyclic antidepressants, e.g. venlafaxine and mirtazapine) may also elevate seizure likelihood.⁷

Would talking therapy treatments help? 

Clinical guidelines stress that depression is assessed for and treated in adults, young people and children with epilepsy.⁹ As per guidance, therapy is considered a mainstay of mental health treatment, with Cognitive Behavioural Therapy (CBT) heavily utilised as the first option.

CBT encourages patients to pinpoint the connections between their thoughts, feelings and behaviours. It is increasingly being offered remotely, via digital platforms, video calling and telephone; these approaches to CBT delivery help to expand the availability of therapy to individuals who struggle with accessibility for face-to-face sessions.⁹

Summary

We hope this article helps to clarify any of your queries and reassures you that you are not alone in facing these struggles. There is always support on hand for managing mental health alongside epilepsy. Seeking advice from your GP or neurologist should be your first point of contact, and they can signpost you to further help and guidance if needed.