Atypical Clinical Manifestations Of Depression In Epilepsy

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As stated above, PWE may often experience depressive disorders that do not meet any Diagnostic and Statistical Manual of Mental Disorders diagnostic criteria or may present symptoms of depression intermittently on what is considered today as a sub-syndromal form of depression. In one study that used Diagnostic and Statistical Manual of Mental Disorders, Third edition Revised (DSM-III-R) criteria, 50% of depressive disorders had to be classified as atypical depression [10], while this occurred in 25% of depressive disorders in a separate study that used DSM-IV criteria [11]. In a review of the literature, Blumer and Altshuler concluded that the atypical clinical expressions of depression are relatively frequent in PWE [12]. These episodes are more likely to resemble a dysthymic disorder, with respect to the symptom severity; in these forms of depression, symptoms last for periods ranging between several hours and several days that are interrupted by symptom-free periods of similar duration. We have used the term dysthymic-like disorder of epilepsy (DLDE) when referring to them [13]. DLDE may consist of anhedonia with or without feelings of hopelessness and helplessness, fatigue, irritability, poor frustration tolerance, and mood liability with recurrent bouts of crying. Some patients also reported changes in appetite and sleep patterns and problems with concentration. Most symptoms exhibited a waxing and waning course, with repeated interspersed symptom-free periods of one to several days' duration. These dysthymic-like disorders also have a negative impact on these patients' quality of life and often can have intermixed episodes of major depression. In open trials, two-thirds of patients with these episodes have been found to experience a complete symptom remission with the use of anti-depressant drugs of the selective serotonin reuptake inhibitor (SSRI) family [13].

It is important for clinicians to recognize whether the symptoms and/or episodes of depression and anxiety are interictal or peri-ictal. Such distinction is significant since interictal symptoms/episodes respond well to pharmacotherapy, while peri-ictal do not.

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