Pakistan Journal of Professional Psychology: Research & Practice
2006, Vol. 1, No. 1, 10-18
Psychological Correlates of Epilepsy
Erum Irshad and Maher Bano
Department of Psychology, University of Peshawar
Peshawar, N.W.F.P., Pakistan.
The main objective of the present research was to investigate the vulnerability of epileptics
towards various psychological disorders. It was hypothesized that epileptics are significantly
different from non-epileptics in terms of their vulnerability to psychological disorders. The
sample included 30 epileptics (i.e. grandmal, myoclonic, primary partial seizures, temporal
lobe) from Institute of Neurosciences, Hayat Shaheed Teaching Hospital and Mental
Hospital Peshawar and 30 non-epileptics volunteers were selected from the population of
Peshawar University. Human Figure Drawing Test (HFDT) and Minnesota Multiphasic
Personality Inventory (MMPI-1) were administered individually on each participant.
Results indicated significant qualitative and quantitative differences between epileptics and
non-epileptics. Epileptics scored higher than non-epileptics on several clinical scales of
MMPI: Among epileptics, patients with temporal lobe epilepsy showed higher mean scores
on emotional indicators (of HFDT) as compared to other epileptics and non-epileptics
suggesting that epileptic group may have more emotional problems. Therefore, it was
concluded that epileptic patients were more anxious, aggressive, insecure and on the whole
had poor self-concept and more symptoms of depression.
Epilepsy is the common neurological problem, timing of seizures thought to be related to light of the
evenly distributed throughout the world. It is full moon and called lunaticos epileptics by Julius
estimated that every 200th person (0.5 percent of the Firmicuis Maternus in the fourth century AD (Adams,
population) suffers from epilepsy. Prevalence among Klinge & Keiser, 1973). In the later half of 19th century,
children is reported to be higher i.e. roughly every 70th first
neuronal
theory
of
epilepsy
defined
it
as
child (1.4 % of all children) is affected (Bett, 2000).
Epilepsy has been defined as a recurrent paroxysmal
disorder of cerebral function characterized by sudden,
brief attacks of altered consciousness, motor activity,
sensory phenomena or inappropriate behavior caused
by abnormal excessive discharge of cerebral neurons
(Dennis, 1991).
The history of epilepsy has close links with
psychiatry. Both have links with gods, demons,
witches, supernatural and have evoked prejudice,
disaffection, and malediction from other members of
society. Both illnesses can be found in the earliest of
medical writings but further, their symbiotic
relationship has been a persistent historical theme.
While Greeks referred epilepsy as sacred disease,
resulting from the invasion of the body by a god,
Hippocrates (460-377 BC) on the contrary declared it
a natural affliction with hereditary origin. Hill (1981)
reported views of Hippocrates that “Melancholic
ordinarily become epileptics, and epileptics
melancholic''. Historical writings describe association
between the moon, epilepsy and insanity. In Rome
epilepsy was known as morbidus lunaticus. The
occasional, sudden, excessive, rapid and local
discharge of gray matter (Reynolds, 1986).
In electrophysiological study of patients with
psychomotor surgeries, scientists were impressed with
the association of EEG abnormalities in the anterior
temporal area with disturbances in personality, since
then the concept has expanded and an enormous,
controversial literature has evolved relating temporal
lobe epilepsy to personality disorders (Lennox, 1992).
Epidemiological study by Pond (1989) has suggested
that as many as one-third or more patients with active
epilepsy have significantly disabling additional
psychological problems, which range from cognitive
impairment and behaviour disorders to psychiatric
illness of all types, especially depression and anxiety
(Hill, 1981).
The nature, scale and complexity of its associated
psychological disorders emphasize that epilepsy sits
firmly on the bridge or interface between neurology
and psychiatry and that the study of these associations
can be expected to illuminate other aspects of these
two disciplines (Trimble & Reynolds, 1976). It is
impossible to identify a single cause of the majority of
PSYCHOLOGICAL CORRELATES OF EPILEPSY 11
cases of epilepsy. These cases are known as idiopathic 4) Temporal lobe epilepsy
but about one-third of these cases are symptomatic, 'Partial complex ' seizures arise in the temporal
suggesting there is a definite etiological factor. lobe of the brain and since this region has a low
Symptomatic epilepsy could be due to prenatal epileptic threshold, this type of seizure is relatively
injury, metabolic defects, malformations and common, accounting for about one third of all
disorders, infections, postnatal trauma, brain tumor epileptics. They mainly occur in the first twenty years
and vascular disease. Apart from etiological factors, of life.
there are some precipitating factors such as stress or Many studies have been carried out on emotional
fatigue, illness, flashing lights (photic epilepsy), aspects of epilepsy. Zimmerman (1951) carried out a
falling asleep or waking up, physical posture, hyper- detailed study of 100 epileptic children aged 3 to 16.
ventilation, music and noise, drugs, poisons and Epilepsy of symptomatic origin was said to display
alcohol, increase in body fluid, hypoglycemia and more “personality deviation” on the Rorschach test
alternation, and stoppage or withdrawal of medication. than the other cases. Daly (1975) described the
psychiatric symptoms of 100 non-institutionalized
Classification of Epilepsy patients with temporal lobe lesion, and noted 15 with
ictal mood changes of whom ten were said to be
Idiopathic Epilepsy dysphoric. Williams (1956) studied 100 patients who
In idiopathic epilepsy, no specific cause can be felt an emotional experience as part of an epileptic
found and virtually all patients with this type of attack. The ictal emotions observed were fear,
epilepsy require anti-convulsant drug therapy. depression, pleasure, displeasure and possibly anger.
Glasser (1988) studied psychiatric symptoms in 25
Symptomatic Epilepsy children with psychomotor epilepsy. Nineteen of the
Although in symptomatic epilepsy, a primary 25 children were psychiatrically disturbed and
disease may be recognised, patients may still require displayed a common picture of excitability, irritability,
anticonvulsant, either because the primary condition is nervousness, hyperactivity, aggression, temper
not amenable to therapy or they are waiting for tantrums, and depression. Gudmundesson (1966) in a
primary therapy such as surgery for a tumour. Each of survey of Iceland population compared the prevalence
these two groups can show any of the seizure types: (1) rates of psychiatric illness in epileptics and non-
Partial seizures (2) Generalized seizures. epileptics. 25 percent of epileptics showed neurotic
symptoms, 50 percent had some type of abnormal
The four major types of epilepsy which are personality, and 8 percent were psychotic. In another
focused in this study are: study by Bell in 2002, who used Middlesex Hospital
Questionnair and Crown-Crisp Experiential Index
1)
Grand Mal (CCEI) to assess the phenomenology and frequency of
It is the most dramatic manifestation of the disease psychopathology in a group of 281 epileptic patients.
and can be very frightening for the onlooker. During The epileptic group as a whole was found to have
the seizures the patient can severely injure himself and higher anxiety and depression scores than normal
at the end of seizure, he may at first glance appears to control population.
be dead. The present research was conducted to
investigate
the
difference
between
epileptic
and
2)
Myoclonic matched non-epileptic groups in terms of their
Myoclonic-atonic seizures occur mostly between vulnerability to various psychological disorders. It
the third and fifth year of life and are a reflection of the also aimed to study the emotional and behavioral
developmental stage of the brain. They are associated correlates of epilepsy.
with severe mental retardation and progressive brain
disease. Hypotheses
1. Participants with epilepsy are more vulnerable
3)
Partial Epilepsy to psychological disorders as compared to non-
A 'partial elementary' seizure may occur at any epileptics.
age, and the nature of its manifestation depends on the 2. Participants with epilepsy show greater
site of the epileptogenic focus in the motosensory number of emotional indicator on HFDT as compared
cortex of the brain. to non-epileptics.
3. Participants with epilepsy will score higher on
12 ERUM IRSHAD AND MAHER BANO
MMPI depression scale as compared to non- Sundburg (1961) it is second only to Rorschach in
epileptics. frequency of use in hospitals and clinics in the United
States. The drawings are analyzed for sign of
Method unconscious needs, conflicts, and personality traits
Sample when used as a projective technique by the clinicians.
The sample consisted of sixty male participants 4) Minnesota Multiphasic Personality Inventory -
ranging in age from 20 to 45 years (mean age was 32.4 1 (MMPI-1)
years for both groups). The reason to choose this age It is a self-report inventory designed to provide an
range was to reduce the possibility of inclusion of objective assessment of some of the major personality
those patients with early development of damage or characteristics that affect personal and social
those having other cognitive deficits. 30 participants adjustment. The MMPI has had wide acceptance and
were epileptics and 30 non-epileptics. All epileptics is used especially by clinical psychologists
were randomly selected through purposive sampling (Thorndike & Hagen, 1995). It evaluates in a
from psychiatry wards of Hayat Shaheed Teaching quantitative form those traits that are commonly
Hospital, Mental hospital, and Institute of Neuro- considered abnormal. The original test contains 550
sciences, Peshawar. The epileptic group included statements but its “Urdu translation” (Mirza, 1977)
patients diagnosed by psychiatrist as suffering from contains 399 items covering a wide range of subject
any of the four types of epilepsy (grand mal, matter. According to the author the total number of
myoclonic, primary partial seizures and temporal lob items used to obtain three validity scores and nine
epilepsy). The duration of their illness was not more clinical scales are 399 whereas remaining 156 items
than one year and they never received any anti- are used in secondary scales. Scoring the inventory is
convulsant medication as yet. They were initially purely objective and is carried out by hand scoring
diagnosed using DSM-IV criteria and EEG was keys. In the present research the Urdu version (Mirza,
performed to confirm the diagnosis. The non-epileptic 1977) was used. The Minnesota Multiphasic
group consisted of volunteers from the population Personality Inventory items cover areas such as health,
residing in Peshawar University. The participants were psychosomatic symptoms, neurological disorders and
carefully matched with epileptic group on variables of motor disturbances, sexual, religious, political, and
age, education and socio-economic status. social attitudes, educational, occupational, family and
marital questions, and many well-known neurotic or
Instruments psychotic symptoms.
1)
Semi-structured Interview 5) Diagnostic and Statistical Mannual of Mental
Semi
structured
interview
was
conducted
to Disorders (DSM-IV):
gather information regarding family, medical and DSM-IV was used to confirm the diagnosis of
psychiatric history and mental status examination. different psychological disorders among epileptic
group in two groups and to rule out any disorder in
2)
Electro- Encephalo Graph (E.E.G) non-epileptic group.
A
simple technique for recording electrical
activity of brain was developed in the early 1930's by Procedure
Hans Berger. EEG's has proved to be a valuable tool
for studying such variables as sleep walking, The patients were contacted at psychiatry wards of
monitoring depth of anaesthesia, diagnosing epilepsy Hayat Shaheed Teaching Hospital, Institute of
and brain damage. However, EEG measures were used Neurosciences and Mental hospital, Peshawar. During
in the present research to diagnose and select epileptic initial meeting each patient was motivated to
group. participate in the study being conducted through
explaining the purpose of the study to them. After
3)
Human Figure Drawing Test (H F D T): getting their consents to participate, they were
HFDT is a test to assess mental maturity based on individually assessed at a disturbance free place inside
work of Goodenough (1947) on children's drawings the hospital. The assessment was carried out in two
and paintings. It is also widely used as a projective phases.
technique to find out underlying psychological
process. As
a
projective
technique
according
to
PSYCHOLOGICAL CORRELATES OF EPILEPSY 13
Table 1
Prevalence of psychiatric disorders in epileptic group according to DSM-IV criteria
Grand Mal
(n=7) Myoclonic
(n=7) Primary Partial
seizures (n=8) Temporal
(n=8)
1 Obsessive
compulsive
2 Anxiety Attacks
3 Borderline
psychosis
4
Depression
Hypochondriasis
Generalized
Anxiety
Depression
Obsessive
compulsive
Borderline
psychosis
Borderline
psychosis
Depression
Depression
Depression
Generalized
Anxiety
5 Depression
6
7
8
Depression Psychosis
Depression
Depression
Depression
Total f (%) 3/7 (43) 5/7 (71) 5/8 (71) 7/8 (88)
Phase I
In this phase, each patient was interviewed to
collect information regarding demographic variables,
such as family, medical and psychiatric history and
mental status examination.
Phase II
Table 2
t-test analysis of epileptics and non-epileptics on
Human Figure Drawing Test (N = 60)
In this phase, MMPI and Human Figure Drawing **** = p < .0001
Test (HFDT) were administered to each subject with
an interval of at least 24 hours, to avoid boredom and
fatigue. Similar assessment procedures were adopted
with matched group of non-epileptics with the
exception of EEG which was initially used to diagnose
A significant difference between epileptics and non-
epileptics was found on HFDT scores as shown in
table 2, which shows that epileptics were more
vulnerable to emotional problems than non-epileptics.
epilepsy. Psychiatric diagnosis was made using DSM- Table 3
IV. One way analysis of variance for four groups of
Results
Analysis of variance and t-test were applied to
analyse data with the help of Statistical Package for
Social Sciences (SPSS).
Psychiatric problems were diagnosed with the
help of DSM IV. Results in Table 1 reflects that two
third (20/30=66.6%) of the epileptic group had some
psychiatric illness, half of those had depression.
Anxiety and borderline psychosis were the two other
types of disorder found in the epileptic group.
epileptics on human figures drawing test (emotional
indicators).
Source of
Variance
df
SS
MS
F
Between
Groups
4
160.63
40.16
39.28****
Within
Groups
5
56.22
1.02
Total
59
216.85
41.17
To find out vulnerability to emotional problems in **** = p < .0001
two group, t-test was used.
S. No
Groups
M
SD
df
t-value
Epileptics
4.16
1.26
58
12.31****
Non-epileptics
.93
.69
14 ERUM IRSHAD AND MAHER BANO
Table 3 shows result of one way of analysis of Table 5
variance that reveals a significant difference among 4 Number of expressed emotional indicators through
epileptic groups, regarding emotional indicators Human Figure Drawing Test by epileptics (n = 30) and
measured through HFDT. non-epileptics (n = 30).
Table 4
Sr.No Emotional indicators E NE
Number of emotional indicators of four group of
epileptics on human figures drawing test. 1 Poor integration of parts
2 Shading of face 17 1
5 0
No of
cases
(n=30)
GM
(n=7)
M
(n=7)
PPS
(n=8)
TL
(n=8)
3 Shading of body or limbs
4 Shading of hands or neck
5 Gross Asymmetry of limbs
6 Slanting figure
7 Big figure
10 3
3 1
3 0
3 0
3 5
4
5
6
7
8
Total
Means
5
5
3
5
-
33
4.71
3
6
5
4
-
28
4.0
3
5
3
4
2
30
3.75
4
4
4
8
7
38
4.75
12 Long arms 2 0
13 Arms clinging to sides of body 2 5
14 Hands cut off or without figures 3 0
15 Legs pressed together 0 5
16 Monster or grotesque figure 11 0
17 No eyes 1 0
18 No body 5 0
19 No arms 1 0
20 No legs 1 0
21 No feet 3 0
22 No neck 13 0
Note: GM = Grand mal, M = Myoclonic,
PPS = Primary Partial seizures, T = Temporal Lobe
Table 4 shows that those with temporal lobe
epilepsy and grand mal epilepsy have slightly higher
mean scores on emotional indicators, which suggests
23 Vacant eyes 14 2
that these groups may have more emotional problems Note: E = epileptics, NE = non-epileptics
as compared to other three groups.
The detailed analysis of 27 emotional indicators of Table 6
HFDT for epileptics and non-apileptics are displayed t-test analysis of epileptics (n=30) and non-epileptics
in table 5. (n=30) on Depression scale of MMPI.
It can be clearly seen that epileptics consistently
got higher scores as compared to non-apileptics on Groups M SD df t-value
majority of HFDT expressed emotional indicators.
Moreover, 6 indicators (number, 1, 3, 10, 16, 22 and
23) were present in almost two-third of the epileptics.
Greater number of emotional indicators on HFDT
shown by epileptics as compared to non-epileptics,
Epileptics
Non-
epileptics
34.30
19.53
6.21
6.45
58 9.04***
indicate that epileptics have poor self-concept, feelings of
*** = p < .001
insecurity and depression. They appear to be immature, t-test analysis was carried out to see the difference
impulsive, aggressive and emotionally disturbed. between epileptics and non-epileptic groups. Table 6
Whereas collective scores of non-epileptics showed less shows that there is a significant difference between
number of emotional indicators showing good self-image depression scores of epileptics and non-epileptics.
and emotionally mature and balanced personalities.
1
2
8
4
2
4
5
3
3
4
8
9
10
Transparencies
Crossed eyes, turned in or out
Teeth
2
1
1
0
0
0
3
3
4
5
4
11
Short arms
11
6
24 Broken lines
8
4
25 Side way glance
4
0
26 Hidden hands
1
1
27 Big head
0
1
Total
126
34
PSYCHOLOGICAL CORRELATES OF EPILEPSY 15
Table 7
Mean, SD, and t test results for epileptics (n = 30) and non-epileptics (n = 30) on different scales of MMPI.
(df = 58).
Epileptic Non-Epileptic
Variable
Mean
SD
Mean
SD
t-value
Sig
Hs
30.80
7.04
14.23
5.74
9.98
.001
D
34.30
6.21
19.53
6.44
9.04
.0001
Hy
25.13
4.15
19.80
5.04
4.47
.0001
Pd
7.60
8.52
8.30
9.22
0.50
.62
Mf
13.93
10.27
12.50
11.93
0.50
.62
Pa
20.40
6.40
13.36
4.56
4.90
.0001
Pt
21.23
7.91
17.03
8.28
2.01
.049
Sc
36.63
5.05
27.70
4.51
57.27
.001
Ma
26.43
10.33
21.10
6.53
2.39
.02
Si
41.10
7.70
26.53
11.19
5.87
.0001
Epileptics reported higher depression than non- epilepsy were found to be suffering from depression
epileptics on MMPI depression scale. in the present study. The results are in line with the
Further analyses were carried out on each MMPI study carried out by Rutter, Graham and Valne (1995)
sub-scale. t-test analyses were conducted separately to who also reported a high incidence of depressive
see the difference between epileptics and non- illness in temporal lobe epileptics. David (1997) in his
epileptics. Table 7 shows that epileptics scored study also found that depression occurred more
significantly higher than non-epileptics on all MMPI frequently in patients with temporal lobe epilepsy than
scales except on Mf and Pd scales. in patients with generalized epilepsy, affecting more
than one in five temporal lobe epileptics. It may be due
Discussion to the fact that temporal lobe is related to the limbic
system, which is the anatomical substrate of emotions
The findings of present research clearly comprised of Hippocampus and Amygdala occupying
differentiated between epileptics and non-epileptics in a central position in the regulation of emotional
terms of their vulnerability to psychological disorders. expression. Therefore, psychological symptoms
Thus first hypothesis that epileptics are more frequently occur with seizures arising in the medial
vulnerable to psychological disorders was supported. temporal lobe.
Among thirty epileptics, two third were diagnosed as Results of the present study indicate that epileptics
suffering from different psychological disorders, are prone to depression or depressive feelings because
which include psychosis, depression, generalized personality difficulties acquired by having epilepsy,
anxiety, obsessive compulsive disorder, especially dependency, general lack of social skills
hypochondriasis and general symptoms of anxiety. and low self-esteem, combined with parental over
The results support the findings of Pond & Bidwell protectiveness and prejudice, may cause problems in
(1989) who suggested that as many as one third or finding friends and work. This, in turn may lead to
more patients with active epilepsy have significantly social isolation, feelings of rejection, frustration and
disabling additional psychological problems ranging dependency. Small (1972) also found that temporal
from the cognitive impairment and behavioural lobe epileptics would display more psychopathology
disorders to psychiatric illnesses of all types, than patients with other kinds of epilepsy.
especially depression and anxiety. Greater number of emotional indicators on HFDT
Among epileptics, majority with temporal lobe were
shown
by
epileptics
as
compared
to
non-
16 ERUM IRSHAD AND MAHER BANO
epileptics, which confirmed the second hypothesis epileptics. High scores of epileptics on these scales
indicating that epileptics have poor self-concept, suggests that they are concerned about their health, are
feelings of insecurity and depression. They appear to prone to worry and are more emotional, sentimental,
be immature, impulsive, aggressive and emotionally dissatisfied, aloof, apathic, cautious and withdrawn.
disturbed. Whereas collective scores of non-epileptics They are suspicious and sensitive about others
showed less number of emotional indicators showing perception about themselves. A possible reason of this
good self-image and emotionally mature and balanced may be the fact that epilepsy is considered a stigma in
personalities. Within epileptic group, those with our society. As a result, epileptics develop feeling of
temporal lobe epilepsy showed high mean score on insecurity, worry and suspiciousness. The high scores
HFDT as compared to other groups of epileptics of epileptics on paranoia scale suggested that
indicating greater personality changes than those with epileptics were prone to worry, sensitive, emotional
temporal lobe epilepsy. These findings are in line with and readily becoming ego involved in various
what was found by Berent (1992) in his study that activities. In contrast, the low scores on paranoia scale
temporal lobe epileptics complained of more of non-epileptics suggest the balance in personality
irritability, impaired concentration and severe and decisiveness.
depression. Nuffield (1995) also demonstrated in his The high scores of epileptics on Sc scale suggested
study that temporal lobe epileptics had high that epileptics were emotionally disarticulated,
aggression and low neuroticism rating while those irritable, resentful, aggressive, stubborn and
with generalized seizures showed the reverse trend i.e. sentimental. Low scores of non-epileptics on this scale
low aggression and high neuroticism ratings. characterized them as cautious, conventional,
The detail interpretation of responses of temporal responsible and self-controlled.
lobe epileptics on HFDT revealed that temporal lobe The social introversion scale (Si) measures the
epileptics have very poor self-concept, low self- tendency to withdraw from social contact with others.
esteem, and unstable personalities. They appeared to High scores of epileptics show that they are slow,
be aggressive, impulsive, immature, insecure, fearful, stereotyped, lacking originality in approach to
stubborn, negative minded and perceive themselves as problems. They are rigid in thoughts and action, overly
ridiculous individuals who are not fully accepted by controlled inhibited and lack confidence in their own
others. The findings of this study strongly support the abilities. Low scores of non-epileptic suggest that they
third hypothesis i.e. patients suffering from temporal are sociable, versatile, talkative, assertive and
lobe epilepsy will show greater changes in personality adventurous.
(i.e. ego-centricity low self-esteem, proneness to A comparison of MMPI profiles of epileptics and
aggressive outbursts) as compared to patients having non-epileptics revealed that epileptics were more
other kinds of epilepsy. vulnerable to develop psychological problems,
On the other hand, results indicated that the most especially depression. These results are also supported
dominant and recurrent features of epileptic group on by other studies measuring psychological profiles of
the whole were aggression, immaturity and poorly epileptics on different scales i.e. Rorschach Inkblot
integrated personalities. They also appeared to be test, Crown's Word Ranking Test and Maudsley
anxious about their bodily functions, egocentric, Personality Inventory (Zimmerman, 1951).
dependent, depressed and had vague perception of the All these personality changes may be inevitable
world which result in difficulty in reaching out to the because of the nature of the disease. Being subject to
world and toward others. unnecessary stigmatization and labeling, enhances
Significantly higher mean score of epileptics as their disability in society related to the prejudice about
compared to non-epileptics show that they have this disorder. Moreover, when a physician
relatively high risk to develop psychological disorders communicates the diagnosis of epilepsy to the patient,
which is also in line with their diagnoses based on case people quickly learn to see the status of epileptic as a
history information. Epileptics high score on social and personal liability. This special view of the
depression scale of MMPI-1 as compared to non- world predisposes individuals to conceal their
epileptics, confirmed our fourth hypothesis, i.e. condition and its medical label from others. Unlike
epileptics will score higher on depression scale of physical handicaps that are always visible, epilepsy
MMPI-1 as compared to non-epileptics. evokes little support from the community. People with
Scores of participants on six clinical scales of epilepsy are particularly stigmatized group. The
MMPI-1 also reflect significant differences in seizures speak up unannounced in a dramatic manner
personality
characteristics
of
epileptics
and
non- and cares not for social etiquette. The fear of loss of
PSYCHOLOGICAL CORRELATES OF EPILEPSY 17
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