The interictal dysphoric disorder: recognition, pathogenesis, and treatment of the major psychiatric disorder of epilepsy.

The unawareness of psychiatrists about the importance of epilepsy dates back half a century, when epilepsy became considered an ordinary neurologic disorder. Epileptic seizures, however, can be provoked in every human being. Epilepsy is an extraordinary disorder that, beyond its well-known neurologic complexities, tends to become complicated with a wide range of specific psychiatric changes; they occur on the establishment of a temporal-limbic focus of intermittent excessive neuronal excitatory activity that produces increasingly inhibitory responses. These changes are distinct from those related to the two major psychiatric spheres for which a genetic basis is established, i.e., the manic-depressive and schizophrenic disorders, and represent a genetic sphere of its own. Apart from more subtle personality changes and the serious late complications of interictal psychoses and suicidal episodes, the key psychiatric syndrome associated with epilepsy consists of the interictal dysphoric disorder, with its characteristic intermittent and pleomorphic symptomatology. This disorder was clearly identified about a century ago by Kraepelin, when he established a comprehensive basis for the modern classification of the psychiatric disorders, at a time when epilepsy represented an area of major interest to psychiatrists. A practical method of recognizing the dysphoric disorder is reported. The disorder tends to be very treatable by combining psychotropic (chiefly antidepressant) with antiepileptic medication. The variations in treatment approach required are discussed and illustrated by representative case studies. Psychiatrists must become familiar with the psychiatric aspects of epilepsy to be able to assist the neurologists who focus on the neural complexities of the illness. They also must become able to recognize, among their own patients, the presence of a subictal dysphoric disorder that requires the same treatment as the interictal dysphoric disorder; combined treatment with antidepressant and antiepileptic medication is likewise indicated for the premenstrual dysphoric disorder, a condition that appears to belong to the spectrum of epilepsy-related psychiatric disorders. Furthermore, they must learn how an ignored population in their care, epilepsy patients confined to state hospitals, can be properly treated. Of particular importance is the need for psychiatrists to become familiar with the role of the paroxysmal affects in the general human condition, with their basic conflict to be intermittently angry and irascible yet otherwise good-natured, helpful, and religious--a conflict that tends to be particularly accentuated among patients with the "Sacred Disease."