It used to be confidently stated that bipolar disorder was rare in patients with epilepsy (Wolf, 1982) . Such statements were made prior to the use of standardized diagnostic manuals such as the DSM-IV, and were also based on clinical impression rather than being assessed by the use of rating scales. It was accepted however that in the context of the postictal state, patients could develop a post-ictal psychosis, the features of which were often manic or hypomanic, although more generally the presentation was one of a mixed affective state often with psychotic features. A recent study (Kanner et al, 2004) of the postictal symptoms of 100 patients noted postictal hypomanic symptoms in 22 patients, often with associated psychotic phenomenology. Nishida et al. (2006) recently showed that postictal mania has a distinct position among mental disorders observed in the postictal period. Postictal manic episodes last for a longer period than postictal psychotic episodes. They have a higher frequency of recurrence than postictal psychoses and are associated with an older age at onset, electroencephalogram (EEG) frontal discharges and right hemisphere involvement.
In the study of Ettinger et al. (2005), bipolar symptoms were revealed in 12.2% of the epilepsy patients, which was twice as common as in people with asthma, and seven times as common as in the healthy comparison group. Of those who in the screening process were rated as potential patients with bipolar symptoms, nearly 50% were rated by a physician as having a bipolar disorder.
These data raise some doubts about the previous suggestions that bipolar disorder is rare in people with epilepsy, and raise doubts as to our knowledge of the association between these two disorders. The older discussions related more to classical manic-depressive disorder, as opposed to the concept of the bipolar spectrum, which is currently the focus of psychiatric interest. However, it is clearly evident that more studies are warranted to clarify the prevalence of bipolar disorder in epilepsy and the possible impact on social and quality-of-life measures.
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