Major Psychiatric Disorders Subsequent to Treating Epilepsy by Vagus Nerve Stimulation

Purpose. The goal of this work was documentation of incidence, phenomenology, pathogenesis, and treatment of psychiatric disorders occurring subsequent to treating epilepsy by vagus nerve stimulation (VNS).Methods. In a series of 81 patients treated by VNS, all patients who developed major psychiatric complications underwent systematic psychiatric evaluation and treatment with psychotropic medication; VNS was modified if necessary.Results. After the seizure frequency was reduced by at least 75%, 7 of 81 patients (9%) developed major psychiatric disorders: Six became severely dysphoric (5 with catastrophic rage and 4 with psychotic symptoms), and one became psychotic. All 7 patients had experienced dysphoric disorders and 2 had experienced psychotic episodes prior to the VNS treatment. Five patients had frequent daily seizures prior to treatment. Remission or satisfactory improvement was achieved with psychotropic medication in 6 patients, aided by decreasing or interrupting VNS in two patients. One patient was noncompliant and suffered a fatal outcome.Conclusion. Severe interictal dysphoric disorders associated with catastrophic rage and psychotic episodes may develop on suppressing seizures by VNS in patients with previous epilepsy-related psychiatric disorders. Patients with multiple daily seizures may be more vulnerable to this occurrence. The phenomenon corresponds to the common finding of interictal dysphoric and psychotic symptoms emerging when inhibitory mechanisms predominate (alternative psychiatric disorders in the absence of seizures, or forced normalization of the EEG). The dysphoric symptom of catastrophic rage appears to occur more often on seizure suppression by VNS than by antiepileptic drugs. Psychiatric intervention, primarily with antidepressant medication, must be available to secure a good outcome; decrease of VNS may occasionally be required.     

Postoperative psychoses in epileptic patients after temporal lobectomy

Introduction – Psychosis is the most severe psychiatric complication after epilepsy surgery. Patients and methods – We evaluated postoperatively at 1 year the psychoses of a series of 57 adult patients with intractable epilepsy who underwent temporal lobe surgery. Results – Five patients (8.8%) developed postoperative psychosis. Two (3.5%) of these 5 revealed postictal psychotic episodes in connection with persisting seizures, both of them had had similar episodes even preoperatively. Two patients (3.5%) exhibited a definite and one patient (1.8%) a probable de novo schizophrenia. Conclusion – Our findings clearly emphasize the need for careful postoperative psychiatric follow-up for patients with temporal lobectomy.     

Suicide in epilepsy: psychopathology,pathogenesis, and prevention

OBJECTIVE: Death by suicide among patients with epilepsy has found scant psychiatric attention, yet it may occur at the rate reported among patients with manic-depressive illness. We aim to clarify the psychopathology and pathogenesis of suicide in epilepsy and to document an effective method of prevention.METHOD: A total of 10,739 patients with epilepsy were seen at the Epi-Care Center in Memphis from 1987 to 1999. The patients with significant psychiatric complications were evaluated systematically and treated with an increasingly effective psychopharmacologic approach.RESULTS: Five suicides were registered during the 12-year period. All occurred in patients with longstanding complex partial seizures and dysphoric disorder a short time after full control of the seizures was achieved. During the last 8years of the 12-year period, more effective pharmacotherapy of the psychiatric complications of epilepsy was used (augmented antidepressant medication), and the two suicides that still occurred had eluded this treatment. Review of earlier series confirms that suicide tends to occur particularly among patients with chronic epilepsy who have obtained good control of their seizures; suicide may occur during interictal dysphoric episodes with or without psychotic features or in a state of postictal depression.CONCLUSIONS: Suppression of seizures in longstanding epilepsy may be associated with suicidal risk. The psychotoxic effect of predominant inhibitory mechanisms appears to be the crucial pathogenetic factor in all suicides. The number of suicides in our series is a fraction of that expected based on previous reports and indicates that prevention by psychopharmacologic treatment is available.     

Psicosis epiléptica periictal,una causa de psicosis reversible

Introduction

Epileptic psychoses are categorised as peri-ictal and interictal according to their relationship with the occurrence of seizures. There is a close temporal relationship between peri-ictal psychosis and seizures, and psychosis may present before (preictal), during (ictal) or after seizures (postictal). Epileptic psychoses usually have acute initial and final phases, with a short symptom duration and complete remission with a risk of recurrence. There is no temporal relationship between interictal or chronic psychosis and epileptic seizures. Another type of epileptic psychosis is related to the response to epilepsy treatment: epileptic psychosis caused by the phenomenon of forced normalisation (alternative psychosis), which includes epileptic psychosis secondary to epilepsy surgery. Although combination treatment with antiepileptic and neuroleptic drugs is now widely used to manage this condition, there are no standard treatment guidelines for epileptic psychosis.

Clinical cases

We present 5 cases of peri-ictal epileptic psychosis in which we observed an excellent response to treatment with levetiracetam. Good control was achieved over both seizures and psychotic episodes. Levetiracetam was used in association with neuroleptic drugs with no adverse effects, and our patients did not require high doses of the latter.

Conclusions

Categorising psychotic states associated with epilepsy according to their temporal relationship with seizures is clinically and prognostically useful because it provides important information regarding disease treatment and progression. The treatment of peri-ictal or acute mental disorders is based on epileptic seizure control, while the treatment of interictal or chronic disorders has more in common with managing disorders which are purely psychiatric in origin. In addition to improving the patient's quality of life and reducing disability, achieving strict control over seizures may also prevent the development of interictal psychosis. For this reason, we believe that establishing a treatment protocol for such cases is necessary.     

Psychiatric outcome of epilepsy surgery in patients with psychosis and temporal lobe drug-resistant epilepsy: A prospective case series

ObjectivesTemporal lobe resistant epilepsy has been associated with a high incidence of psychotic disorders; however, there are many controversies; while some patients get better after surgery from their psychiatric condition, others develop psychosis or de novo depression. The aim of this study was to determine the psychiatric and seizure outcome after epilepsy surgery in patients with a previous history of psychoses.MethodsSurgical candidates with temporal lobe drug-resistant epilepsy and a positive history of psychosis diagnosed during the presurgical psychiatric assessment were included. A two-year prospective follow-up was determined after surgery. The DSM-IV Structural Interview, GAF (global assessment of functionality, DSM-IV), Ictal Classification for psychoses, and Engel's classification were used. The Student t test and chi-square–Fisher tests were used.ResultsDuring 2000–2010, 89 patients were admitted to the epilepsy surgery program, 14 patients (15.7%) presented psychoses and were included in this series. After surgery, six patients (43%) did not develop any psychiatric complications, three patients (21%) with chronic interictal psychosis continued with no exacerbation, three patients (21%) developed acute and transient psychotic symptoms, and two patients (14%) developed de novo depression. Seizure outcome was Engel class I-II in 10 patients (71%). Total GAF scores were higher after surgery in patients found to be in Engel class I–II (p < 0.05).ConclusionsPatients with comorbid psychosis and temporal lobe drug-resistant epilepsy may benefit from epilepsy surgery under close psychiatric supervision.     

Violence and Epilepsy: A Close Relation Between Violence and Postictal Psychosis

Summary: Purpose: We investigated the incidence of well-directed violent behavior and suicide attempts in patients with temporal lobe epilepsy, with special attention to postictal psychosis.
Methods: We compared 57 episodes of postictal psychosis with 62 episodes of acute interictal (or alternative) psychosis and with 134 complex partial seizures. All patients were matched for age and for age at onset of seizures.
Results: The incidence of well-directed violent behavior against human beings was significantly higher (23%) during postictal psychotic episodes than during acute interictal episodes (5%) and postictal confusion (1%). Suicide attempts were also more frequent during postictal psychosis (7%) than during either acute interictal psychosis (2%) or postictal confusion (0%).
Conclusions: Our study showed that well-directed violent and self-destructive behavior was not a feature of epileptic psychosis in general but a specific hallmark of postictal psychosis.     

Association of fear auras with mood and anxiety disorders after temporal lobectomy

PURPOSE: Epilepsy has been associated with increased occurrence of behavioral disorders. Auras reflect abnormal stimulation of brain areas in close proximity to regions from which clinical seizures originate. The purpose of our study was to investigate whether fear auras are associated with a higher rate of mood and anxiety disorders before and 1 year after temporal lobectomy. METHODS: Twenty-two patients with fear auras were compared with matched groups with other auras and no auras. Neurologic and neuropsychological evaluations before, 1-2 months after, and 1 year after temporal lobectomy were reviewed for mood and anxiety disorders and psychotropic medication treatment. A logistic regression model examined effects of patient group and psychiatric status on postoperative psychiatric status. RESULTS: The majority of patients in the three groups experienced mood and anxiety disorders before surgery. Mood and anxiety disorders declined in the control, but not in the fear aura group after surgery. Presence of auras at 1 year after surgery was not related to psychiatric outcome. Postoperative mood and anxiety disorders were more common in patients with persistence of seizures and in those in the fear group who were seizure free. The minority of patients in all groups underwent psychotropic treatment before surgery, but the majority with fear auras underwent treatment after surgery. CONCLUSIONS: Postoperative mood and anxiety disorders were more common in fear aura patients after temporal lobectomy, in particular, if seizure free. Possible mechanisms include the role of the amygdala in fear conditioning, the concepts of forced normalization, and kindling.     

Psychiatric morbidity, quality of life, and disability in mesial temporal lobe epilepsy patients before and after anterior temporal lobectomy

Considerable interest has been focused on the psychiatric complications of medically refractory temporal lobe epilepsy (TLE) before and after epilepsy surgery. The aim of the present study was to evaluate the psychiatric status, quality of life, and level of disability in medically refractory mesial temporal lobe epilepsy (MTLE) patients, a homogenous subgroup of patients with TLE, before and after anterior temporal lobectomy (ATL). The study population consisted of 22 patients with medically refractory MTLE who were candidates for ATL. Patients were examined before surgery as well as in the third and sixth months of the postoperative period. Psychiatric diagnosis was determined by using SCID-I. To rate the severity of psychiatric disorders, BPRS, HDRS, and HARS were employed on each visit. WHO-DAS-II and WHOQOL-BREF were used to determine the level of disability and quality of life. Preoperatively, six patients had a psychiatric diagnosis. Three months after surgery, six of the patients had psychiatric diagnoses. Five of these six patients had not been previously diagnosed. There was no significant difference between preoperative and postoperative follow-up evaluations in terms of HDRS, HARS, and BPRS ratings. With respect to the total scores and domains of WHO-DAS-II, the change in pre- and postoperative evaluations was statistically significant only for the social life attendance domain. There was no significant difference in the mean scores on the WHOQOL-BREF domains or on the first question about general evaluation of quality of life. For the second question on the level of satisfaction with health, the difference between the three ratings was statistically significant. Preoperative and postoperative rates of psychiatric disorders in our sample were low. While social phobia was frequently seen preoperatively, the postoperative period was spearheaded by major depressive disorder. The decrease in disability in attendance to social life and improvement in the quality of health were in concordance with the literature, indicating the positive results of surgical treatment of epilepsy on quality of life. This study suggests that surgical intervention might be one of the causes of postoperative psychiatric disorders in patients with MTLE.     

Concurrent Illnesses in Adults with Childhood-Onset Epilepsy: A Population-Based 35-Year Follow-Up Study

Summary: Purpose: To ascertain the occurrence of concurrent illnesses in adults with epilepsy since childhood.
Method: After a mean follow-up of 35 years of a prospective, population-based long-term followed patient cohort with epilepsy since childhood, comorbidity was examined in 176 surviving (100 of them with epilepsy only) and 44 dead patients and in random and employee controls.
Results: Somatic comorbidity varied from 84 to 95% in patients and from 67 to 74% in controls. No significantly increased risk of somatic diseases could be shown. Psychosomatic disorders were associated in 46-74% of patients and in 42-75% of controls, and psychiatric disorders were associated in 11-23% of patients and in 7% of controls. As compared with random controls, patients with epilepsy had only a 4.0- to 4.2-fold risk of psychiatric disorders or of combinations of somatic, psychosomatic, and/or psychiatric disorders. Patients received psychotropic drugs 8.6 times more frequently than employee controls. The risk for psychiatric and psychsomatic disorders was higher than expected in patients with childhood-onset epilepsy, regardless of whether or not they were still receiving antiepileptic drugs (AEDs).
Conclusion: Epilepsy per se, but not AEDs, has an apparent association with the occurrence of psychiatric and psychosomatic disorders. Risk for somatic comorbidity is not increased.     

Surgical treatment of temporal lobe epilepsy with interictal psychosis: results of six cases

We describe the postsurgical outcome of six patients with medically intractable temporal lobe epilepsy and interictal psychosis who underwent temporal lobe resection. All patients were submitted to a comprehensive presurgical investigation, including prolonged video-EEG monitoring. Despite their psychotic disorders, all patients were able to provide informed consent and we were able to complete the investigation of all cases. Surgical complications occurred in two cases. Seizure outcome was Engel class I (free from incapacitating seizures) in all except one patient. There was no worsening of their psychoses. Until now, there has been relative improvement in the mental conditions of five patients. Although psychosis has been considered by some authors as a contraindication to epilepsy surgery, with appropriate psychiatric intervention, patients with refractory epilepsy and chronic interictal psychosis may be submitted to prolonged presurgical investigation and undergo surgery successfully.