LETTERS TO THE EDITOR
Epilepsy and Anxiety
To the Editor:
In their recent paper, Goldstein and Harden review
the evolutionary significance of anxiety, theories
about the pathophysiology of anxiety and its relation-
ships to epilepsy, and the different ways that anxiety
presents in patients with epilepsy (1). They also pro-
vide the current view of the neuroanatomical under-
pinnings of anxiety and, in doing so, remind us again
of the ever-narrowing gap between neurology and
psychiatry.
The authors raise many questions for those of us
who see patients with epilepsy and comorbid anxiety,
especially concerning diagnosis. When should the
psychiatrist consider epilepsy in the differential diag-
nosis of anxiety and pursue the diagnosis with an EEG
or long-term EEG monitoring? In a given patient with
epilepsy, is anxiety part of an aura, or is it an ictal,
postictal, or interictal phenomenon? Is it occurring
reactively as a fear of recurrence of the seizures or is it
an independent comorbid disorder? The article also
raises the question of treatment. When is an anticon-
vulsant the treatment of choice?
Certainly, further research is needed. Studies using
a factor analysis of the various symptoms of anxiety
may be helpful in guiding the diagnostic evaluation
and choice of treatment. Specialized EEG assessments
of standard psychiatric cases of anxiety may lead to
further understanding of state-versus-trait anxiety.
Exploring ways to reverse the seizure-lowering effects
of anxiety, perhaps through relaxation techniques,
may benefit patients with epilepsy and comorbid anx-
iety. Studies should measure the impact of such inter-
ventions on seizure frequency and severity, as well as
quality of life. Because the same anatomical structures
are implicated whether anxiety is part of an anxiety
disorder or epilepsy, an intriguing research question
relates to the pathophysiological difference between
these entities even when the phenotypic expression is
the same.
The authors are to be commended for advocating
further study of the interrelatedness of seizure disor-
ders and anxiety. Such attention may further our un-
derstanding of how mind and body interact in the
brain, leading to more complete interventions.
REFERENCE
1. Goldstein MA, Harden CL. Epilepsy and anxiety. Epilepsy Be-
hav 2000;1:228–34.
Bernard Vaccaro, M.D.
1
Gregory Fricchione, M.D.
Harvard Medical School
75 Francis Street
Boston, Massachusetts 02215
doi:10.1006/ebeh.2000.0116
Congenital Adrenal Hyperplasia Presenting
as Nonepileptic Seizures
To the Editor:
Dr. Herzog presents a very interesting case of what
he proposes were nonepileptic seizures that were
physiologically induced by sedatory neuroactive ste-
roids. Though Dr. Herzog argues eloquently for the
anxiogenic etiology for these apparently rather stereo-
typical paroxysmal events, he also mentions that the
changes effected by the endocrine dysfunction also
have proconvulsant and convulsive effects. The epi-
sodes of concern were with onset in late childhood,
occurrence up to a half-dozen times each month, and
duration ranging from 5 to 20 minutes, after which she
would appear vague, puzzled, and tired. Apparently,
the EEG did show occasional epileptiform discharges.
1
To whom correspondence should be addressed. Fax: (617) 738-
1275.
Epilepsy & Behavior 1, 362–365 (2000)
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2000 by Academic Press
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