An Epilepsy Comorbidity to Watch Out For
An Epilepsy Comorbidity to Watch Out For
Andrew N. Wilner, MD: Greetings. I am Dr Andrew Wilner. Welcome to Medscape. Today I have the pleasure of welcoming an old friend to Medscape, Dr Alan Ettinger. Alan is an epileptologist and director of the epilepsy program in Lake Success, New York. Alan has a keen interest in epilepsy and comorbidities, particularly psychiatric comorbidities. He has a book about that and a more recent book on neurologic differential diagnosis. I've spotted a paper that Alan recently published on epilepsy and attention-deficit/hyperactivity disorder (ADHD), and I thought the findings were very intriguing. Alan, tell us about your research.
Alan B. Ettinger, MD: Thank you very much, Andy. It is really a pleasure to have this opportunity to talk about these findings and this new study. As you know, I have long had an interest in the psychiatric comorbidities of epilepsy, and in past years we have tried to bring awareness to the neurologic community about psychiatric comorbidities such as depression, anxiety, and mood instability (eg, bipolar symptoms). But in recent years we realized that not much had been done to examine the possibility of ADHD symptoms in adults with epilepsy.
We know from previous studies that ADHD appears to have an elevated prevalence in children with epilepsy, but to our best knowledge, ADHD in adults with epilepsy has never been examined. The purpose of our study was, in a very exploratory way, to see whether ADHD symptoms represent a problem in adults with epilepsy. Our study was a major epidemiologic survey. After screening hundreds of thousands of individuals using validated questionnaires, to really have confidence that we were surveying individuals with epilepsy of diverse severity and diverse frequency, we came down to about 1400 adults with epilepsy, which enabled us to launch this study.
The study involved the administration of a number of well-validated surveys. We asked questions about ADHD by administering a survey that has been validated and used by the World Health Organization, called the Adult ADHD Self-Report Scale (ASRS), consisting of about six questions, to enable us to get a sense of symptoms of ADHD. I would like to clarify that our study was really looking at ADHD symptoms and by no means did we look at ADHD diagnosis. ADHD diagnosis may be a bit of a different entity and is something that needs to be clarified in our future studies.
What we found, to our great shock, was that nearly 1 out of 5 adults with epilepsy actually met criteria for moderate ADHD symptoms. By applying other validated surveys for depression, anxiety, and psychosocial disability (in the domains of functioning in the family, functioning at work, being employed, etc.), we found that individuals with ADHD symptoms were much more likely to have impairments and disabilities in all of these other areas. We feel that our study is yet another wake-up call to the clinician for the need to not only focus on seizures and seizure control, but also to actually screen for some of the things that we have studied. In particular, clinicians need to be doing a better job of screening for depression, anxiety, and now ADHD.
Dr Wilner: If you have epilepsy, you have a brain disease, which might impair your concentration, attention to detail, and ability to stay on task. You have your ADHD-type symptoms, plus you are taking a medication that is also making you sleepy or drowsy and making it harder to function. How do you sort out all of these factors?
Dr Ettinger: I think you are raising really excellent issues. The actual cause of ADHD symptoms is something that needs to be further clarified. There are many possibilities to explain this relationship. We used to think of psychiatric comorbidities as a simple reaction to having epilepsy. For example, we used to simplistically believe that if you had epilepsy, it is really a "crappy thing" and who wouldn't be depressed? So epilepsy must be the reason for the depression.
However, we have learned with further studies that, in fact, these psychiatric comorbidities, such as depression, can actually precede epilepsy, and if you have depression, it can be a risk factor for epilepsy. It is not that depression is causing epilepsy but more likely that depression—and even ADHD in children, as seen in other studies—are risk factors for epilepsy. It is more likely that there is a common underlying central nervous system problem, and this can manifest with epilepsy or it can manifest with psychiatric issues. The order of these manifestations is not necessarily set. In some individuals, psychiatric comorbidities may manifest first, and in other individuals, epilepsy may occur first.
Alternatively, it may be the effects of the seizures themselves and it could also be the treatments that we use for epilepsy. There are a number of medications that are notoriously associated with altered attention, such as barbiturates or topiramate, for example. It may be a mixture of these kinds of things.
Our next study is designed to clarify further what having ADHD symptoms represents in epilepsy. Is it really the same entity that we traditionally think of or is it a different entity? Even if it is different, this finding in our current study has very important implications, because ADHD itself (ie, the symptoms) can be very impairing and yet it is very amenable to treatment, particularly with stimulants.
There was controversy about whether stimulants could lower seizure threshold but, in fact, the majority of anecdotal experience and literature is very reassuring. Most clinicians take the point of view that if there is an opportunity to treat ADHD symptoms, there is hope that the use of ADHD treatment can make a tremendous difference in the quality of life of our adult patients with epilepsy.
Dr Wilner: It sounds as if your research is allowing us to have a more holistic approach to treating people with epilepsy. Maybe we can consider additional treatment modalities in addition to controlling seizures to improve their quality of life. Thank you very much for joining us on Medscape.
Andrew N. Wilner, MD: Greetings. I am Dr Andrew Wilner. Welcome to Medscape. Today I have the pleasure of welcoming an old friend to Medscape, Dr Alan Ettinger. Alan is an epileptologist and director of the epilepsy program in Lake Success, New York. Alan has a keen interest in epilepsy and comorbidities, particularly psychiatric comorbidities. He has a book about that and a more recent book on neurologic differential diagnosis. I've spotted a paper that Alan recently published on epilepsy and attention-deficit/hyperactivity disorder (ADHD), and I thought the findings were very intriguing. Alan, tell us about your research.
Alan B. Ettinger, MD: Thank you very much, Andy. It is really a pleasure to have this opportunity to talk about these findings and this new study. As you know, I have long had an interest in the psychiatric comorbidities of epilepsy, and in past years we have tried to bring awareness to the neurologic community about psychiatric comorbidities such as depression, anxiety, and mood instability (eg, bipolar symptoms). But in recent years we realized that not much had been done to examine the possibility of ADHD symptoms in adults with epilepsy.
We know from previous studies that ADHD appears to have an elevated prevalence in children with epilepsy, but to our best knowledge, ADHD in adults with epilepsy has never been examined. The purpose of our study was, in a very exploratory way, to see whether ADHD symptoms represent a problem in adults with epilepsy. Our study was a major epidemiologic survey. After screening hundreds of thousands of individuals using validated questionnaires, to really have confidence that we were surveying individuals with epilepsy of diverse severity and diverse frequency, we came down to about 1400 adults with epilepsy, which enabled us to launch this study.
The study involved the administration of a number of well-validated surveys. We asked questions about ADHD by administering a survey that has been validated and used by the World Health Organization, called the Adult ADHD Self-Report Scale (ASRS), consisting of about six questions, to enable us to get a sense of symptoms of ADHD. I would like to clarify that our study was really looking at ADHD symptoms and by no means did we look at ADHD diagnosis. ADHD diagnosis may be a bit of a different entity and is something that needs to be clarified in our future studies.
What we found, to our great shock, was that nearly 1 out of 5 adults with epilepsy actually met criteria for moderate ADHD symptoms. By applying other validated surveys for depression, anxiety, and psychosocial disability (in the domains of functioning in the family, functioning at work, being employed, etc.), we found that individuals with ADHD symptoms were much more likely to have impairments and disabilities in all of these other areas. We feel that our study is yet another wake-up call to the clinician for the need to not only focus on seizures and seizure control, but also to actually screen for some of the things that we have studied. In particular, clinicians need to be doing a better job of screening for depression, anxiety, and now ADHD.
Dr Wilner: If you have epilepsy, you have a brain disease, which might impair your concentration, attention to detail, and ability to stay on task. You have your ADHD-type symptoms, plus you are taking a medication that is also making you sleepy or drowsy and making it harder to function. How do you sort out all of these factors?
Dr Ettinger: I think you are raising really excellent issues. The actual cause of ADHD symptoms is something that needs to be further clarified. There are many possibilities to explain this relationship. We used to think of psychiatric comorbidities as a simple reaction to having epilepsy. For example, we used to simplistically believe that if you had epilepsy, it is really a "crappy thing" and who wouldn't be depressed? So epilepsy must be the reason for the depression.
However, we have learned with further studies that, in fact, these psychiatric comorbidities, such as depression, can actually precede epilepsy, and if you have depression, it can be a risk factor for epilepsy. It is not that depression is causing epilepsy but more likely that depression—and even ADHD in children, as seen in other studies—are risk factors for epilepsy. It is more likely that there is a common underlying central nervous system problem, and this can manifest with epilepsy or it can manifest with psychiatric issues. The order of these manifestations is not necessarily set. In some individuals, psychiatric comorbidities may manifest first, and in other individuals, epilepsy may occur first.
Alternatively, it may be the effects of the seizures themselves and it could also be the treatments that we use for epilepsy. There are a number of medications that are notoriously associated with altered attention, such as barbiturates or topiramate, for example. It may be a mixture of these kinds of things.
Our next study is designed to clarify further what having ADHD symptoms represents in epilepsy. Is it really the same entity that we traditionally think of or is it a different entity? Even if it is different, this finding in our current study has very important implications, because ADHD itself (ie, the symptoms) can be very impairing and yet it is very amenable to treatment, particularly with stimulants.
There was controversy about whether stimulants could lower seizure threshold but, in fact, the majority of anecdotal experience and literature is very reassuring. Most clinicians take the point of view that if there is an opportunity to treat ADHD symptoms, there is hope that the use of ADHD treatment can make a tremendous difference in the quality of life of our adult patients with epilepsy.
Dr Wilner: It sounds as if your research is allowing us to have a more holistic approach to treating people with epilepsy. Maybe we can consider additional treatment modalities in addition to controlling seizures to improve their quality of life. Thank you very much for joining us on Medscape.
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