Social Anxiety Disorder and Epilepsy

By: Natalie Bailey

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Social Anxiety Disorder and Epilepsy

Social phobia, commonly referred to as social anxiety disorder (SAD), is outlined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) as a fear of becoming the focal point of scrutiny in social situations, manifesting as dread or anxiety, which prompts the affected individual to adopt avoidant behaviors. Despite the lack of research on the convergence of SAD and epilepsy, a notable comorbidity between these two conditions can be discovered (Heersink et al., 2015). The presence of epilepsy in an individual predisposes them to anxiety surrounding social engagement.

Particular anxiety-inducing thoughts contribute to the development of SAD along with other anxieties, including anticipatory seizure anxiety, epileptic social phobia, epileptic panic disorder, and seizure phobia (Hingray et al., 2019). Individuals with epilepsy who have developed SAD suffer from a spectrum of associated impairments, encompassing but not limited to unemployment, marital dissolution, diminished fertility, and social stigma, thereby inadvertently exacerbating maladaptive thoughts and avoidance behaviors associated with SAD (Wei et al., 2021). Moreover, the unpredictable onset of seizures and the potential for an epileptic episode to occur regardless of the setting create a heightened sense of vulnerability in affected individuals (Mula, 2013). The co-occurrence of SAD in individuals with epilepsy engenders socially elusive behaviors designed to avert a public seizure occurrence and the perceived scrutiny associated.

Statistics and Correlations

Generally, the incidence of mental health disorders among individuals with epilepsy falls between 25.9% and 44.0%, notably surpassing the estimated 20% prevalence in the non-affected population. However, when specifically considering anxiety disorders, the prevalence rate for individuals with epilepsy is 22.8%, contrasting with the 11.2% prevalence rate observed in the general populace (Tellez-Zenteno et al., 2007). Furthermore, those with heightened anxiety levels reported a more pronounced impact of epilepsy on their well-being and experienced elevated seizure intensity. Notably, social anxiety in individuals with epilepsy demonstrates a significant and positive correlation with seizure severity, the overall impact of epilepsy, lower knowledge pertaining to the diagnosis, decreased disclosure of their condition, and a heightened fear of social stigma (Heersink et al., 2015). Conversely, a reciprocal relationship exists between the two disorders; having SAD correlates with increased seizure frequency and severity, just as the frequency and severity of seizures in people with epilepsy constitute as risk factors for the subsequent development of SAD (Lu et al., 2021).

When focusing specifically on SAD, individuals with epilepsy exhibit a fivefold increased likelihood of acquiring this diagnosis (Rai et al., 2012), with various studies reporting prevalence rates ranging approximately from 6% to 21%, contingent on cultural factors (Lu et al., 2021). A population-based study involving Canadian residents with epilepsy produced a 22.8% prevalence rate of anxiety, more than double the 11% prevalence observed in their non-epileptic counterparts (Brandt et al., 2010). A separate study in South Korea revealed that 11% of individuals with temporal lobe epilepsy experienced social interaction anxiety, while 21% grappled with social phobia (Han et al., 2019). Varying prevalence rates have been documented in England, where one study reported a rate of 6%, and in China, where another revealed a rate of 0.6% (Wei et al., 2021). Various theories accounting for discrepancies in SAD rates in epileptic (and nonepileptic) populations can be a byproduct of differences between collectivist and individualist cultures, cultural stigmas associated with mental health, and the interplay of quality of life with population socioeconomic status.

Self-esteem and Stigma

In contrast to the general populace, individuals afflicted with epilepsy commonly exhibit diminished self-esteem and an augmented sense of perceived stigma within the environment, alongside concurrent manifestations of social anxiety and phobia. Perceived stigma is intricately linked to diverse psychological factors influencing an individual’s general well-being, encompassing aspects such as anxiety, personality traits, and problem-solving capabilities (Han et al., 2019). In the context of individuals contending with both epilepsy and SAD, the prevalence of diminished self-esteem demonstrates no statistically significant variance across sociodemographic factors, including age, gender, income, and socioeconomic status, among others. Individuals hailing from diverse backgrounds who are grappling with SAD and epilepsy uniformly manifest heightened levels of fear and avoidance, particularly pertaining to the apprehension of sudden-onset epileptic seizures. This apprehension, in turn, conditions them to associate the fear of unanticipated seizures with an aversion to public spaces, a reluctance to leave their residences, and concerns regarding social perceptions (Ranjan et al., 2019).

Individuals experiencing heightened seizure frequency exhibit lower self-esteem and heightened fear avoidance behaviors, alongside increased stigma perception, recurrent isolation, and social restrictions (Ranjan et al., 2019). Expressions of embarrassment, social alienation, discomfort, avoidance, discrimination, and predominant feelings of inferiority are frequently reported by individuals with epilepsy. When analyzed, it was found that people with epilepsy and SAD possess a prevailing sentiment of believing they are of a lower social value than their non-epileptic counterparts (Wei et al., 2021).

However, the perception of felt stigma and discrimination appears to be more reflective of an individual with epilepsy’s internalized social anxiety, failing to portray an accurate evaluation of the sentiments of the general population. This negative self-perception within the epilepsy community is less a reflection of the actual feelings held by the broader populace and more indicative of an individual’s apprehension regarding societal perceptions, rendering them more prone to interpreting external verbal and nonverbal language cues as manifestations of felt stigma (Heersink et al., 2015). The correlation between diminished self-esteem and perceived stigma among individuals with epilepsy can be predominantly attributed to the facet of SAD, making them more susceptible to avoiding social situations and misinterpreting interpersonal interactions. Nonetheless, the experience of felt stigma exerts a substantial and adverse influence on the overall health, happiness, and quality of life of individuals with epilepsy.

Contributing Brain Regions

With regard to abnormalities in cerebral regions of the brain, discernible differences between individuals with epilepsy and their non-epileptic counterparts not only exist in terms of brain structures but also disparities of activation patterns depending on whether or not an individual with epilepsy experiences comorbid SAD. The primarily notable distinctions are observed in amygdala and hippocampus activity, cortical thickness, and limbic system functionality.

The amygdala, a pivotal center for emotional processing within the brain, primarily governs sentiments such as fear and anger. The hippocampus, responsible for memory functions, and the cerebral cortex, surrounding the brain and serving as an information processing center, work alongside the limbic system, which contributes to threat identification and the initiation of fight-or-flight responses. All of these provinces collectively constitute focal points of differentiation. The limbic system includes both the amygdala and hippocampus, among other regions. Therefore, seizures originating from the limbic system engender heightened manifestations of fear-related symptoms, which are significant in the genesis of SAD and avoidance behaviors (Hingray et al., 2019).

In individuals concurrently affected with epilepsy and SAD, the amygdala assumes a pivotal role in facilitating the experience of fear and the apprehension of a potentially dangerous environment, thereby contributing to avoidance behaviors in social settings commonly observed in people with SAD. Furthermore, the hippocampus plays a central role in the retrieval of fearful memories associated with social situations (Mula, 2013). Notably, individuals presenting with epilepsy and SAD exhibit significantly larger volumes of the amygdala, although hippocampus sizes remain relatively comparable to control groups. Moreover, these patients demonstrated cortical thinning in specific brain regions, such as the left medial orbitofrontal, right lateral orbitofrontal, and right frontal pole (Jones et al., 2015).

Furthermore, it was discerned that individuals contending with SAD and epilepsy exhibited a heightened familial predisposition to anxiety disorders compared to those with epilepsy who do not possess SAD. This difference suggests that the identified structural abnormalities in the brain may belong to a genetic and biological origin rather than being environmentally induced (Jones et al., 2015).

Available Treatment

In the treatment of SAD among individuals with epilepsy, conventional therapeutic approaches involve the application of cognitive behavioral therapy (CBT) and acceptance and commitment therapy (ACT). The utilization of these techniques aims to assist individuals in effectively managing the emotional challenges related to their diagnosis, particularly feelings of shame and scrutiny, as well as addressing feelings of a perceived social stigma (Heersink et al., 2015). It is noteworthy that a lack of knowledge regarding epilepsy and its specific classification is correlated with heightened levels of SAD and social distress. Therefore, informing individuals about their condition and maintaining a reliable support system and healthy family dynamics may mitigate negative emotions and avoidant behaviors associated with SAD in the context of epilepsy (Han et al., 2019). Information revolves around diagnostic information and preventative measures, encompassing actions to be taken before, during, and after seizure onset (Hingray et al., 2019).

Complementary to psychotherapeutic interventions, pharmacological treatments have demonstrated efficacy in the management of SAD in the epilepsy population. Primary pharmaceutical interventions include selective serotonin-reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) (Brandt et al., 2010). These inhibitors prolong the presence of neurotransmitters such as serotonin and norepinephrine in the synaptic gap, thereby extending their impact and compensating for potential deficiencies in molecule density. However, during the 4 to 6-week latency period, before the full therapeutic effect of SSRIs and SNRIs takes effect, benzodiazepines may be prescribed in conjunction with CBT. Antiepileptic drugs, including benzodiazepines, contribute to anxiety symptom mediation by modulating calcium channels and facilitating gamma-aminobutyric acid (GABA) inhibition. Notably, certain SSRIs, such as sertraline and paroxetine, exhibit efficiency in managing SAD and depressive symptoms in individuals with and without epilepsy (Mula, 2013). However, it is imperative to underscore that the use of SSRIs and benzodiazepines should be considered adjunctive to psychotherapeutic interventions rather than serving as a universal solution for every individual’s challenges with mental and physiological health.

References:

Brandt, C., Schoendienst, M., Trentowska, M., May, T. W., Pohlmann-Eden, B., Tuschen-Caffier, B., Schrecke, M., Fueratsch, N., Witte-Boelt, K., & Ebner, A. (2010). Prevalence of Anxiety Disorders in Patients With Refractory Focal Epilepsy—A Prospective Clinic Based Survey. Epilepsy Currents, 17(2), 259–263. https://doi.org/10.1016/j.yebeh.2009.12.009

Han, S.-H., Kim, K. T., Ryu, H. U., Lee, S.-A., Cho, Y.-J., Kim, J. H., Kang, K.-W., Shin, D. J., Lee, G. H., Hwang, K. J., Kim, Y.-S., Kim, J. B., Kim, J.-E., Lee, S.-Y., & Seo, J.-G. (2019). Factors Associated With Social Anxiety in South Korean Adults With Epilepsy. Epilepsy & Behavior, 101, 106569. https://doi.org/10.1016/j.yebeh.2019.106569

Heersink, M., Kocovski, N. L., MacKenzie, M. B., Denomme, K., & Macrodimitris, S. (2015). Social anxiety and its psychosocial impact on the lives of people with epilepsy. Epilepsy & Behavior, 51, 286–293. https://doi.org/10.1016/j.yebeh.2015.08.003

Hingray, C., McGonigal, A., Kotwas, I., & Micoulaud-Franchi, J.-A. (2019). The Relationship Between Epilepsy and Anxiety Disorders. Current Psychiatry Reports, 21(6). https://doi.org/10.1007/s11920-019-1029-9

Jones, J. E., Jackson, D. C., Chambers, K. L., Dabbs, K., Hsu, D. A., Stafstrom, C. E., Seidenberg, M., & Hermann, B. P. (2015). Children with epilepsy and anxiety: Subcortical and cortical differences. Epilepsia, 56(2), 283–290. https://doi.org/10.1111/epi.12832

Lu, Y., Zhong, R., Li, M., Zhao, Q., Zhang, X., Hu, B., & Lin, W. (2021). Social anxiety is associated with poor quality of life in adults with epilepsy in Northeast China: A cross-sectional study. Epilepsy & Behavior, 117, 107866. https://doi.org/10.1016/j.yebeh.2021.107866

Mula, M. (2013). Treatment of anxiety disorders in epilepsy: An evidence-based approach. Epilepsia, 54(1), 13–18. https://doi.org/10.1111/epi.12101

Rai, D., Kerr, M. P., McManus, S., Jordanova, V., Lewis, G., & Brugha, T. S. (2012). Epilepsy and psychiatric comorbidity: A nationally representative population-based study. Epilepsia, 53(6), 1095–1103. https://doi.org/10.1111/j.1528-1167.2012.03500.x

Ranjan, L. K., Gupta, P. R., & Panday, R. (2019). Social Anxiety and Self-Esteem in Patients with Epilepsy. Journal Of Disability Management and Rehabilitation, 5(1), 15–20.

Tellez-Zenteno, J. F., Patten, S. B., Jetté, N., Williams, J., & Wiebe, S. (2007). Psychiatric comorbidity in epilepsy: a population-based analysis. Epilepsia, 48(12), 2336–2344. https://doi.org/10.1111/j.1528-1167.2007.01222.x

Wei, Z., Ren, L., Yang, L., Liu, C., Cao, M., Yang, Q., Liu, X., Liu, Y., & Deng, Y. (2021). The relationship between social anxiety and felt stigma in patients with epilepsy: A network analysis. Seizure, 92, 76–81. https://doi.org/10.1016/j.seizure.2021.08.014

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