Panda’s Top Tip 🐼
Temporal lobe epilepsy (TLE) can present with prominent psychiatric symptoms that may be mistaken for primary psychiatric disorders. Consider epilepsy when symptoms are episodic, stereotyped, brief, and associated with altered awareness or amnesia.
Key Knowledge
TLE is the most common focal epilepsy in adults in the UK
● Seizures arise from the temporal lobe and often involve the hippocampus or amygdala
● Characteristic features include auras (déjà vu, fear, epigastric rising sensation, sensing an unusual smell), automatisms, and impaired awareness
● Interictal psychiatric symptoms are common, for example mood disorders, anxiety and psychosis
● Diagnosis requires EEG (often needs sleep-deprived or ambulatory monitoring) and MRI
● Psychiatric presentations can delay diagnosis
What is Temporal Lobe Epilepsy?
What is Temporal Lobe Epilepsy?
●Temporal lobe epilepsy is a form of focal epilepsy where seizures originate in the temporal lobe, most commonly the mesial temporal structures (hippocampus, amygdala, parahippocampal gyrus).
Seizure semiology typically includes:
Aura (warning):
●Often the first manifestation
●Epigastric rising sensation (most common)
●Fear or anxiety
●Déjà vu or jamais vu
●Olfactory or gustatory hallucinations (unpleasant smells/tastes)
●Auditory hallucinations or distortions
●Derealisation or depersonalisation
●Emotional experiences (fear, sadness, euphoria)
Impaired awareness:
●The individual appears conscious but is not fully responsive, and may stare blankly into space.
Automatisms:
●Repetitive, purposeless behaviours
●Orofacial (lip smacking, chewing, swallowing)
●Manual (fumbling, picking at clothes, repetitive hand movements)
●Verbal (mumbling, repeated phrases)
Language: loss of ability to speak or speech not making sense.
Post-ictal phase: Confusion, amnesia of the event, drowsiness, headache (may last minutes to hours)
Seizures can range from a matter of seconds to a few minutes in length. Tonic-clonic activity may occur if seizures generalise secondarily.
Interictal psychiatric manifestations:
●Depression (very common, may precede epilepsy diagnosis)
●Anxiety disorders
●Interictal psychosis (schizophrenia-like symptoms)
●Personality changes (historical concept of “temporal lobe personality” is controversial)
●Cognitive impairment (memory difficulties, especially verbal memory if left TLE)
Common causes:
●Hippocampal sclerosis
●Developmental malformations
●Tumours (low-grade gliomas)
●Vascular malformations
●Post-traumatic, post-infectious
Differential Diagnosis for Temporal Lobe Epilepsy
1. Panic disorder
Key distinctions: Panic attacks involve intense fear and autonomic symptoms but lack the stereotyped quality, automatisms, and amnesia of TLE. Panic attacks are usually longer and followed by full recollection. Auras in TLE are brief and often progress to impaired awareness.
2. Psychotic disorders
Key distinctions: People can experience pre-ictal, ictal, inter-ictal and post-ictal psychosis. This can resemble schizophrenia and other psychotic disorders and those with epilepsy have a higher risk of psychosis. People can experience hallucinations and delusional beliefs. Linking their presentations with other symptoms such as aura and automatisms, along with diagnosis of epilepsy on EEG/imaging, helps to differentiate TLE from a primary psychotic disorder
3. Migraine with aura
Key distinctions: Migraine auras are typically visual, develop gradually over minutes, and are followed by headache. TLE auras are usually briefer, involve other sensory modalities (smell, taste, déjà vu), and are followed by impaired awareness or automatisms.
4. Transient ischaemic attacks (TIA)
Key distinctions: TIAs cause negative symptoms (loss of function, weakness, numbness, vision loss), whereas TLE typically causes positive symptoms (hallucinations, automatisms, sensory experiences). TIAs typically occur in those with vascular risk factors and last minutes/hours without recurrence in stereotyped fashion.
5. Functional Seizures
Key distinctions: Functional seizure episodes are often longer, lack stereotyped progression, may have eyes closed, and involve side-to-side head movements or pelvic thrusting (atypical for epilepsy). Importantly, ictal EEG shows no epileptiform activity. However, Epilepsy and Functional Seizures can coexist.
6. Substance use or withdrawal
Key distinctions: Alcohol or benzodiazepine withdrawal can cause seizures, but these are typically generalised tonic-clonic rather than focal. Hallucinogen use can cause perceptual disturbances but they typically lack impaired awareness.
Risk Assessment in Temporal Lobe Epilepsy
●Seizure-related injury – Falls, head injury, burns, drowning (bathing), aspiration
●SUDEP (Sudden Unexpected Death in Epilepsy) – Risk increased by poor seizure control, nocturnal seizures, generalised tonic-clonic seizures
●Driving – DVLA must be notified; seizure-free periods required before driving
●Suicide risk – Increased in epilepsy, particularly with co-morbid depression or psychosis
●Cognitive decline – Repeated seizures may worsen memory and cognitive function
●Medication side effects – Including mood changes, suicidal ideation (especially with levetiracetam, topiramate)
To others:
●Low unless seizures occur during potentially dangerous activities (e.g., driving, operating machinery)
From others:
●Stigma and social isolation
Communication Tips
Communication Tips
Think CASC: TLE often presents to psychiatry. Key skills involve detailed event description, screening for psychiatric comorbidity, and recognising when to suspect epilepsy.
Exploring the episodes:
●”Can you describe exactly what happens during these episodes, from the very beginning?”
●”Do you get any warning that it’s about to happen?”
●”What’s the first thing you notice?” (Explore for aura: fear, déjà vu, rising sensation, smells/tastes)
●”Then what happens next?” (Build a timeline)
●”How long does the whole thing last?”
●”What do other people notice? What do they say you do?”
●”Can you remember what happens during the episode, or is there a gap in your memory?”
●”How do you feel afterwards?” (Post-ictal confusion, headache, tiredness)
Identifying features suggestive of epilepsy:
●”Do the episodes always follow the same pattern?”
●”Do you lose awareness or find yourself ‘not quite there’?”
●”Do you do anything repetitive, such as lip smacking, fumbling with things?”
●”Have you ever bitten your tongue or lost control of your bladder?”
Triggers and frequency:
●”How often do these episodes happen?”
●”Have you noticed any triggers, such as stress, lack of sleep, flashing lights?”
●”Do they ever happen when you’re asleep?”
Impact on functioning:
●”How has this affected your daily life (work, driving, relationships)?”
●”Do you avoid certain situations because you’re worried about having an episode?”
Screen for interictal psychiatric symptoms:
●Mood: “How has your mood been generally, between episodes?”
●Memory: “Have you noticed any problems with your memory?”
●Anxiety: “Do you experience anxiety or worry between episodes?”
●Psychosis: (If indicated) unusual experiences, paranoia, hallucinations
Previous investigations:
●”Have you seen a neurologist or had any tests (brain scans, EEGs)?”
Family history:
●”Does anyone in your family have epilepsy/fits/seizures?”
CASC Practice Scenarios
Scenario 1: History Taking
Candidate Instructions:
You are the liaison psychiatry SpR. You have been asked to review Mr Anthony Blake, a 47-year-old bus driver, on the neurology ward. He was admitted two days ago following a witnessed seizure whilst at home. His wife called an ambulance after finding him unresponsive with urinary incontinence. CT head was normal. EEG showed left temporal sharp waves. Neurology have started levetiracetam 500mg twice daily and requested psychiatric review because Mr Blake has been describing unusual experiences over the past 8 months that his wife fears may be psychiatric in nature.
Please take a history from Mr Blake.
Scenario Summary:
Anthony Blake is a 47-year-old bus driver with new-onset temporal lobe epilepsy. Over the past eight months, he has experienced increasingly frequent auras: rising epigastric sensations, intense fear, déjà vu, and unpleasant olfactory hallucinations (burning rubber smell). These episodes last 1-2 minutes and are followed by confusion and amnesia. His wife has witnessed orofacial automatisms (lip-smacking, chewing) during these episodes. He has been referred to psychiatry previously by his GP for “panic attacks” and received a course of CBT, which did not help. Over the same period, he has become more irritable, low in mood, and has mild memory problems. There is no primary psychiatric disorder and his symptoms are manifestations of temporal lobe epilepsy (ictal and interictal). He is understandably anxious about his driving license and livelihood.
Actor Brief:
You are Anthony Blake, a 47-year-old bus driver for Transport for London, living in London with your wife Pauline, who works part-time as a teaching assistant, and your two teenage daughters, Emma (16) and Sophie (14). Two days ago, you had what the doctors are calling a seizure at home. You don’t remember it happening. Pauline found you on the living room floor, unconscious, and you’d wet yourself. You came round in the ambulance, confused and with a terrible headache. You’ve never had anything like that before, and it’s terrifying because of what it means for your job.
But here’s the thing, over the past 8 months or so, you’ve been having these weird episodes that you now wonder might be connected. They happen maybe two or three times a week, sometimes more. It starts with this odd feeling rising up from your stomach, almost like being in a lift that’s going down too fast. Then you feel intense fear and absolute terror, even though there’s nothing to be afraid of. Everything feels weirdly familiar, like you’ve been in that exact moment before (déjà vu). And you get this horrible smell of burning rubber, really strong, but no one else can smell it.
These episodes only last a minute or two, but afterwards, you feel confused and tired, and you can’t really remember what happened during them. Pauline says that sometimes you smack your lips and chew, and you look “vacant”. She’s been worried about it for months. You thought they were panic attacks and your GP referred you for a course of CBT six months ago, but it didn’t help because you weren’t anxious about anything in particular, these episodes just came out of nowhere.
You’ve also noticed over the past few months that your memory isn’t as sharp as it used to be. You forget names of regular passengers, miss appointments, lose track of conversations. You’ve been more irritable too, snapping at Pauline and the girls over small things, which isn’t like you. Your mood has been lower than normal, and you’re worried about work and feel quite down about everything. You’re sleeping okay but waking up early sometimes.
You don’t drink alcohol much, maybe two or three pints at the weekend. You’ve never used illicit drugs. You have no past psychiatric problems. Your dad had epilepsy, starting in his 50s, though you’d forgotten about that until the doctors asked.
The thing that’s consuming you now is your job. You’ve been a bus driver for 22 years, it’s your whole career, your income, your identity. If you can’t drive, you don’t know what you’ll do. You’re terrified of losing your license. The doctors have already told you that you can’t drive for a year, maybe longer and you’re devastated.
You’re cooperative but anxious throughout the interview. You’re keen to explain the episodes in detail because you’re desperate to understand what’s been happening. You’re worried the doctors think you’re “crazy” or making it up. When asked about the episodes, you describe them carefully; the rising sensation, the fear, the smell, the déjà vu. You don’t volunteer that Pauline has seen you doing odd things (lip-smacking, appearing vacant) unless asked directly about what others have observed. You’re tearful when discussing your job and the impact on your family. You deny any suicidal thoughts but admit you’re scared and worried, but you want to get better and get back to work.
Feedback for Scenario 1
Knowledge & Clinical Skills
●Recognise the key features of temporal lobe epilepsy through systematic exploration of episodic phenomena: auras (epigastric rising sensation, fear, déjà vu, olfactory hallucinations), automatisms, impaired awareness, post-ictal confusion, and amnesia for events
●Distinguish TLE from primary psychiatric disorders (panic disorder, dissociative seizures, psychosis) by focusing on the stereotyped nature of episodes, brief duration, association with automatisms and post-ictal states, and lack of psychological triggers
●Explore both ictal (during seizures) and interictal (between seizures) psychiatric manifestations, recognising that mood disturbance, irritability, and cognitive changes are common in TLE and may have been mistaken for primary psychiatric illness
●Take a detailed collateral history by asking what the patient’s wife has observed during episodes, recognising that patients often have amnesia for ictal events and that witness accounts are crucial for diagnosis
●Assess the psychological impact of a new epilepsy diagnosis, including concerns about driving, employment, identity, and stigma, which have significant implications for mental health and require sensitive exploration
Communication
A good candidate will:
●Use clear, jargon-free language when exploring complex phenomena like auras and automatisms, perhaps using phrases like “warning signs before an episode” rather than assuming the patient understands the medical terminology
●Demonstrate empathy for the occupational and social impact of epilepsy, particularly the loss of driving license for a professional driver, acknowledging that this is life-changing and not minimising concerns
●Explore the patient’s illness beliefs and concerns sensitively
Video
Temporal Lobe Epilepsy | CASC Video – PsychPanda
Authors/Reviewers
Dr Damir Rafi is a Psychiatry Speciality registrar in forensics, currently working in London.
Dr Rebecca Goodall is a Psychiatry Specialty Registrar, specialising in children & adolescents.
Dr Raquel Clark Castillo is a Psychiatry Speciality Registrar specialising in forensics.
References and Resources
World Health Organization. (2019). International classification of diseases for mortality and morbidity statistics (11th ed.). https://icd.who.int/browse11/l-m/en
National Institute for Health and Care Excellence. (2022). Epilepsies in children, young people and adults (NG217). https://www.nice.org.uk/guidance/ng217
Trimble, M. R., & Schmitz, B. (Eds.). (2011). The neuropsychiatry of epilepsy (2nd ed.). Cambridge University Press.
Epilepsy action, working name of British Epilepsy Association, https://www.epilepsy.org.uk/info/seizures/focal-seizures
Disclaimer:
This article is intended for use as a learning resource for doctors training in Psychiatry in the UK. It is not intended for patients. If you are looking for information about mental health conditions, please visit www.rcpsych.ac.uk/mental-health to find readable, user-friendly and evidence-based information on mental health problems, treatments and other topics written by qualified psychiatrists, with help from patients and carers. If you are looking for help for a mental health condition, please visit https://www.mind.org.uk/ for information about where help is available.
The article was written by UK doctors and cross-checked against various published sources (see Reference list). We endeavour to keep information up to date, but it should not be relied on for clinical decision making. Consult local guidelines and senior colleagues whenever you are not sure.
Related Articles:
Mania History Taking: https://psychpanda.com/mania/
OCD History Taking, Risk & Management: https://psychpanda.com/ocd/
Understanding & Assessing Delusions: https://psychpanda.com/delusions/