British Journal of Psychiatry (1991),159, 822—826
Psychopathology
of People with Mental Handicap and Epilepsy I: Maladaptive Behaviour S. DEBand DAVID HUNTER
One hundredand fifty mentally handicappedpeople (100 from hospital and 50 from the community) with epilepsy were studied along with an individually matched control group of
150 (100 from hospital and 50 from the community) non-epileptic mentally handicapped people. Behaviour was studied using the Profile of Abilities and Adjustment Schedule. Of the total population, 55.3% showed some type of severe behaviour problem. Although the epileptics showed slightly more severe behaviour problems than the non-epileptic group, there was no statistically significant difference between the two groups. Some differences emerged
between the groups when subgroups of epileptics were studied.
The literature on interictal maladaptive behaviour and aggression is confusing. In many studies, the definition of aggression and maladaptive behaviour is unclear. Despite the common belief that aggression
study
(Deb et a!, 1987) where
we were unable
to find any significant difference in the rate of maladaptive behaviour between epileptic adults and a matched control group of non-epileptic adults in a mental handicap institution. One recent
and maladaptive behaviour are more common among epileptics, controlled investigations have consistently reported no overall increase. The only
controlled study conducted by Espie et al (1989)
two controlled studies among epileptic prisoners have also failed to detect raised levels of violence (or seriousness of crime) (Gunn, 1977; Hermann & Whitman, 1984). However, recent reviews of the
involving residents in a hospital for people with a mental handicap concluded that “¿disturbed behaviour was not associated with epilepsy per se... [although] a small sub-group of subjects who have poorly controlled epilepsy do present greater
literature suggest that the relationship between aggressive behaviour and epilepsy is due to non specific factors which are common to both violent
behavioural management problems―.Similar obser
populations and patients with epilepsy, the most significant of which is associated brain damage
handicap and epilepsy who lived in the community and attended day centres (Gilles et al, 1989).
(Fenwick, 1986). The literature on the psychopathology of mentally handicapped epileptics is sparse and has many loopholes. Eyman et a! (1969) studied the mental handicap population in three large hospitals in the USA and showed hyperactivity along with other
The evidence for a correlation between maladaptive behaviour and epilepsy among the mentally handi
factors such as aggression, difficulties in eating/dressing
vations were made by the same authors when they compared behaviour among people with mental
capped
group of 511 non-epileptic mentally handicapped people in Arizona Children's Colony. Significant differences were found in 16 out of 21 factors (mainly hyperactivity, withdrawal and aggression directed to others, self or objects). However,
Corbett (1981), in the Camberwell study, did not find any significant difference in the frequency of behaviour disturbance between epileptic and non-epileptic children with severe mental handicap. This finding was also supported by our previous
fault in such studies
controls.
1975; Stevens & Hermann,
among the institutionalised mentally handicapped epileptics. In another study, Capes & Moore (1970) compared 21 factors of maladaptive behaviour control
The commonest
When used, many
apparent differences disappear (Kligrnan & Goldberg,
speech problems and to be more common
between 229 epileptic and a non-matched
is poor.
is the lack of adequate
1981). We therefore
studied psychopathological aspects of mentally handicapped people with epilepsy under the headings of (a) Maladaptive Behaviour, (b) Psychiatric Illness and (c) Personality Disorders, and compared them with an individually mentally handicapped
matched control group of people without epilepsy. Method
All epileptic residents
of two hospitals
in Leicester,
UK,
for people with mental handicap were included (n = 100). These two hospitals have different wards for adults with varying degrees of handicap with or without associated physical and/or behavioural problems. All the epileptic attenders of two day centres for mentally handicapped adults (n = 50) were also included. A control group of 100 non-epileptic mentally handicapped residents of the same
822
PSYCHOPATHOLOGY
IN MENTAL
HANDICAP
AND EPILEPSY:
I
823
undertaken during the study period. In these cases, the
hospitals and 50 non-epileptic mentally handicapped attenders of the same day centres was also studied. The non
consultant
epileptic controls were individually matched with the epileptic mentally handicapped group on the basis of their
patient's seizure type. Spike, polyspikes, spike wave, sharp wave, sharp and slow waves were accepted as epileptiform
(a) age, (b) sex, (c) level of intelligence as measured by
activities
various psychometric tests, (d) level of communication (expressive speech, comprehension and clarity of speech),
Information concerning type and dosage of anticonvulsants was obtained from the medical records. Anticonvulsant
who reported on the EEG was unaware of each
in EEG.
(e) sensory impairment (vision and hearing), (f) living
drug levels were estimated approximately 12 hours after
environment (in the case of hospital patients, a similar ward setting; in the case of community patients, either a hostel, or home with relatives), (g) length of hospital stay or attendance at day centre, and (Ii) associated chronic physical
administration
illnesses.
Psychiatry Unit, London. This scale was created by the combination of two scales, the Disability Assessment
Intelligence was tested by various psychometric tests (WAIS, WAIS-R, Raven's progressive matrices, Peabody
Picture Vocabulary Test, Vineland Social Maturity Scale) and was expressed in terms of IQ. In almost all the cases,
IQ measurementswere recorded from the psychologist's reports in the medical records. Level of communication,
sensory impairments and chronic physical illness were measured by ‘¿Profile of Abilities and Adjustment' schedule (PAA). Classification
of mental handicap
was undertaken
according to The Ninth Revision of the International Classification of Diseases(mild mental handicap, IQ 70-50; moderate mental handicap, IQ 49—35;severe mental handicap, IQ below 35)(ICD-9;
World Health Organization,
1978). As much information as possible was gathered from medical
case records
and carers regarding
the cause of
mental handicap. Epilepsy was defined according to Gunn & Fenton's
of the last dose.
Aspects of behaviour (including maladaptive behaviour) were measured with the PAA scale. The PAA was designed by Dr Lorna Wing and her colleagues from the MRC Social Schedule (Holmes et a!, 1982) and the Star Profile (Williams, 1982). Holmes et a! (1982) undertook an extensive reliability study of the Disability Assessment Schedule and found high inter-rater, inter-informant and test—retestreliability. Reliability scores on the maladaptive behaviour section were between 78% and 93%.
The followingsectionsof the PAA schedulewere used in our study: VI Vision and hearing; VIII Vocal corn munication; IX Maladaptive behaviour which includes (a) physical aggression, (b) destructiveness, (c) overactivity,
(d)auention seekingbehaviour, (e) self-injury, (f)wandering, (g) screaming and other noises, (h) temper tantrum, (i)
disturbingothersat night, (j) objectionablepersonalhabits, (k) throwing objects aimlessly, (1)antisocial behaviour and (m) sexual delinquency; X Co-operation; XI Psychiatric and physical condition (this includes subsections such as mood,
irritability,chronicphysicalillness,and variouspsychiatric (1969)operationalcriteriaof at leastthree epilepticseizures illnesses); XII Social relationship; XIII Social interaction; in two years.Drug-inducedepilepsyand febrileconvulsions XIV Stereotyped behaviour; and XV Echolalia. were excluded. We divided the epileptic group into ‘¿active' Sections of the PAA used in our study were scored on (those who had sustained seizures during the previous 12 a ranked scale. The PAA is an observer-rated scale. The informant was either a senior member of the ward nursing months) and ‘¿non-active' epileptics (those who had not sustained any seizures within the previous 12 months). staff or, in the case of the community-based population, Classification
of epilepsy was undertaken
on the basis of
clinical signs and according to the International Classifi
cationof EpilepticSeizures(TheCommissiononClassification and Terminology for the International League Against Epilepsy, 1981). A detailed description of epileptic attacks was obtained from an eye-witness and where necessary a ‘¿behaviour check-list during seizure' was completed. Information about the age of onset of epilepsy and total duration of epilepsy was obtained from case records, carers and relatives. Severity of epilepsy was measured according
a relative or carer who had known the patient for at least three years. Each of the 13 maladaptive behaviour subscales was rated on a sliding scale of 1 to 6. A score between 1 and 3 signified severe problem and between 4 and 6 signified mild to no problem in each behaviour category. Each person
was then rated according to the number of maladaptive behaviour subscales on which they scored severe rating (i.e.
I to 3). Each personcould, therefore, scorebetween0 and 13 on ‘¿severe behaviour' rating.
DatawereanalysedbycomputerusingtheSPSSXpackage. to the frequencyof seizures.It wasclassifiedas ‘¿frequent'Variables among the epileptic population were compared
@
if seizures occurred more than once a month and ‘¿lesswith the matched control group using the Wilcoxon matched pairs signed rank test (2-tailed), Mann—Whitney frequent' if the frequency was less than one per month. Wherepatientssustainedmore than one seizuretype it was (2-tailed) or (after Yates' correction) and Fisher's exact the most frequent type of seizure that was considered. probability test, where appropriate. However, status epilepticus was discounted. Information concerning seizure frequency was obtained from carers, or,
in the caseof the hospitalpopulation,from nursingrecords. The seizure frequency was estimated for the previous 12 months. Electroencephalogram (EEG) recordings were available on 100 out of 150 epileptic patients. However, less than half of the patients had an EEG recording within the previous 12 months.
For the remaining
patients,
an EEG
was
Results The epilepticgroup contained77menand 73women.Mild mental handicap was diagnosed in 49, 26 were moderately handicapped, and 75 were severely handicapped. The mean age was 40 years (s.d. 13 years) with a range of 20—77years.
Those aged below 40 years numbered 83; 67 were over
824
DEB AND HUNTER
the age of 40. In the hospital there was a significantly higher proportion of severely handicapped people (j@= 15.87, d.f. 1, P
Psychopathology
of People with Mental Handicap and Epilepsy I: Maladaptive Behaviour S. DEBand DAVID HUNTER
One hundredand fifty mentally handicappedpeople (100 from hospital and 50 from the community) with epilepsy were studied along with an individually matched control group of
150 (100 from hospital and 50 from the community) non-epileptic mentally handicapped people. Behaviour was studied using the Profile of Abilities and Adjustment Schedule. Of the total population, 55.3% showed some type of severe behaviour problem. Although the epileptics showed slightly more severe behaviour problems than the non-epileptic group, there was no statistically significant difference between the two groups. Some differences emerged
between the groups when subgroups of epileptics were studied.
The literature on interictal maladaptive behaviour and aggression is confusing. In many studies, the definition of aggression and maladaptive behaviour is unclear. Despite the common belief that aggression
study
(Deb et a!, 1987) where
we were unable
to find any significant difference in the rate of maladaptive behaviour between epileptic adults and a matched control group of non-epileptic adults in a mental handicap institution. One recent
and maladaptive behaviour are more common among epileptics, controlled investigations have consistently reported no overall increase. The only
controlled study conducted by Espie et al (1989)
two controlled studies among epileptic prisoners have also failed to detect raised levels of violence (or seriousness of crime) (Gunn, 1977; Hermann & Whitman, 1984). However, recent reviews of the
involving residents in a hospital for people with a mental handicap concluded that “¿disturbed behaviour was not associated with epilepsy per se... [although] a small sub-group of subjects who have poorly controlled epilepsy do present greater
literature suggest that the relationship between aggressive behaviour and epilepsy is due to non specific factors which are common to both violent
behavioural management problems―.Similar obser
populations and patients with epilepsy, the most significant of which is associated brain damage
handicap and epilepsy who lived in the community and attended day centres (Gilles et al, 1989).
(Fenwick, 1986). The literature on the psychopathology of mentally handicapped epileptics is sparse and has many loopholes. Eyman et a! (1969) studied the mental handicap population in three large hospitals in the USA and showed hyperactivity along with other
The evidence for a correlation between maladaptive behaviour and epilepsy among the mentally handi
factors such as aggression, difficulties in eating/dressing
vations were made by the same authors when they compared behaviour among people with mental
capped
group of 511 non-epileptic mentally handicapped people in Arizona Children's Colony. Significant differences were found in 16 out of 21 factors (mainly hyperactivity, withdrawal and aggression directed to others, self or objects). However,
Corbett (1981), in the Camberwell study, did not find any significant difference in the frequency of behaviour disturbance between epileptic and non-epileptic children with severe mental handicap. This finding was also supported by our previous
fault in such studies
controls.
1975; Stevens & Hermann,
among the institutionalised mentally handicapped epileptics. In another study, Capes & Moore (1970) compared 21 factors of maladaptive behaviour control
The commonest
When used, many
apparent differences disappear (Kligrnan & Goldberg,
speech problems and to be more common
between 229 epileptic and a non-matched
is poor.
is the lack of adequate
1981). We therefore
studied psychopathological aspects of mentally handicapped people with epilepsy under the headings of (a) Maladaptive Behaviour, (b) Psychiatric Illness and (c) Personality Disorders, and compared them with an individually mentally handicapped
matched control group of people without epilepsy. Method
All epileptic residents
of two hospitals
in Leicester,
UK,
for people with mental handicap were included (n = 100). These two hospitals have different wards for adults with varying degrees of handicap with or without associated physical and/or behavioural problems. All the epileptic attenders of two day centres for mentally handicapped adults (n = 50) were also included. A control group of 100 non-epileptic mentally handicapped residents of the same
822
PSYCHOPATHOLOGY
IN MENTAL
HANDICAP
AND EPILEPSY:
I
823
undertaken during the study period. In these cases, the
hospitals and 50 non-epileptic mentally handicapped attenders of the same day centres was also studied. The non
consultant
epileptic controls were individually matched with the epileptic mentally handicapped group on the basis of their
patient's seizure type. Spike, polyspikes, spike wave, sharp wave, sharp and slow waves were accepted as epileptiform
(a) age, (b) sex, (c) level of intelligence as measured by
activities
various psychometric tests, (d) level of communication (expressive speech, comprehension and clarity of speech),
Information concerning type and dosage of anticonvulsants was obtained from the medical records. Anticonvulsant
who reported on the EEG was unaware of each
in EEG.
(e) sensory impairment (vision and hearing), (f) living
drug levels were estimated approximately 12 hours after
environment (in the case of hospital patients, a similar ward setting; in the case of community patients, either a hostel, or home with relatives), (g) length of hospital stay or attendance at day centre, and (Ii) associated chronic physical
administration
illnesses.
Psychiatry Unit, London. This scale was created by the combination of two scales, the Disability Assessment
Intelligence was tested by various psychometric tests (WAIS, WAIS-R, Raven's progressive matrices, Peabody
Picture Vocabulary Test, Vineland Social Maturity Scale) and was expressed in terms of IQ. In almost all the cases,
IQ measurementswere recorded from the psychologist's reports in the medical records. Level of communication,
sensory impairments and chronic physical illness were measured by ‘¿Profile of Abilities and Adjustment' schedule (PAA). Classification
of mental handicap
was undertaken
according to The Ninth Revision of the International Classification of Diseases(mild mental handicap, IQ 70-50; moderate mental handicap, IQ 49—35;severe mental handicap, IQ below 35)(ICD-9;
World Health Organization,
1978). As much information as possible was gathered from medical
case records
and carers regarding
the cause of
mental handicap. Epilepsy was defined according to Gunn & Fenton's
of the last dose.
Aspects of behaviour (including maladaptive behaviour) were measured with the PAA scale. The PAA was designed by Dr Lorna Wing and her colleagues from the MRC Social Schedule (Holmes et a!, 1982) and the Star Profile (Williams, 1982). Holmes et a! (1982) undertook an extensive reliability study of the Disability Assessment Schedule and found high inter-rater, inter-informant and test—retestreliability. Reliability scores on the maladaptive behaviour section were between 78% and 93%.
The followingsectionsof the PAA schedulewere used in our study: VI Vision and hearing; VIII Vocal corn munication; IX Maladaptive behaviour which includes (a) physical aggression, (b) destructiveness, (c) overactivity,
(d)auention seekingbehaviour, (e) self-injury, (f)wandering, (g) screaming and other noises, (h) temper tantrum, (i)
disturbingothersat night, (j) objectionablepersonalhabits, (k) throwing objects aimlessly, (1)antisocial behaviour and (m) sexual delinquency; X Co-operation; XI Psychiatric and physical condition (this includes subsections such as mood,
irritability,chronicphysicalillness,and variouspsychiatric (1969)operationalcriteriaof at leastthree epilepticseizures illnesses); XII Social relationship; XIII Social interaction; in two years.Drug-inducedepilepsyand febrileconvulsions XIV Stereotyped behaviour; and XV Echolalia. were excluded. We divided the epileptic group into ‘¿active' Sections of the PAA used in our study were scored on (those who had sustained seizures during the previous 12 a ranked scale. The PAA is an observer-rated scale. The informant was either a senior member of the ward nursing months) and ‘¿non-active' epileptics (those who had not sustained any seizures within the previous 12 months). staff or, in the case of the community-based population, Classification
of epilepsy was undertaken
on the basis of
clinical signs and according to the International Classifi
cationof EpilepticSeizures(TheCommissiononClassification and Terminology for the International League Against Epilepsy, 1981). A detailed description of epileptic attacks was obtained from an eye-witness and where necessary a ‘¿behaviour check-list during seizure' was completed. Information about the age of onset of epilepsy and total duration of epilepsy was obtained from case records, carers and relatives. Severity of epilepsy was measured according
a relative or carer who had known the patient for at least three years. Each of the 13 maladaptive behaviour subscales was rated on a sliding scale of 1 to 6. A score between 1 and 3 signified severe problem and between 4 and 6 signified mild to no problem in each behaviour category. Each person
was then rated according to the number of maladaptive behaviour subscales on which they scored severe rating (i.e.
I to 3). Each personcould, therefore, scorebetween0 and 13 on ‘¿severe behaviour' rating.
DatawereanalysedbycomputerusingtheSPSSXpackage. to the frequencyof seizures.It wasclassifiedas ‘¿frequent'Variables among the epileptic population were compared
@
if seizures occurred more than once a month and ‘¿lesswith the matched control group using the Wilcoxon matched pairs signed rank test (2-tailed), Mann—Whitney frequent' if the frequency was less than one per month. Wherepatientssustainedmore than one seizuretype it was (2-tailed) or (after Yates' correction) and Fisher's exact the most frequent type of seizure that was considered. probability test, where appropriate. However, status epilepticus was discounted. Information concerning seizure frequency was obtained from carers, or,
in the caseof the hospitalpopulation,from nursingrecords. The seizure frequency was estimated for the previous 12 months. Electroencephalogram (EEG) recordings were available on 100 out of 150 epileptic patients. However, less than half of the patients had an EEG recording within the previous 12 months.
For the remaining
patients,
an EEG
was
Results The epilepticgroup contained77menand 73women.Mild mental handicap was diagnosed in 49, 26 were moderately handicapped, and 75 were severely handicapped. The mean age was 40 years (s.d. 13 years) with a range of 20—77years.
Those aged below 40 years numbered 83; 67 were over
824
DEB AND HUNTER
the age of 40. In the hospital there was a significantly higher proportion of severely handicapped people (j@= 15.87, d.f. 1, P
