“Tell me how do I feel” – Emotion recognition and theory of mind in symptomatic mesial temporal lobe epilepsy

Theory of mind in epilepsy

Epilepsy is characterized by recurrent, chronic, and unprovoked seizures. Epilepsy has a significant negative impact on a patient's quality of life even if seizures are well controlled. In addition to the distress caused by seizures, patients with epilepsy (PwE) may suffer from cognitive impairment with serious social consequences such as poor interpersonal relationships, loss of employment, and reduced social networks. Pathological changes and functional connectivity abnormalities observed in PwE can disrupt the neural network responsible for the theory of mind. Theory of mind is the ability to attribute mental states to other people (intentions, beliefs, and emotions). It is a complex aspect of social cognition and includes cognitive and affective constructs. In recent years, numerous studies have assessed the relationship between social cognition, including the theory of mind, in PwE, and suggested impairment in this domain. Interventions targeting the theory of mind can be potentially helpful in improving the quality of life of PwE.

Social cognition in Idiopathic generalised epilepsies

Social cognition is a set of mental skills necessary to create satisfactory interpersonal relationships and feel a sense of belonging to a social group. Its deficits significantly reduce the quality of life in people with epilepsy. Studies on social cognition and its impairments focus predominantly on people with focal epilepsies. Idiopathic generalised epilepsies are a group of diseases that share similar clinical, prognostic and electrographic characteristics. Despite their typically normal intelligence, people with Idiopathic generalised epilepsies can suffer from learning disabilities and executive dysfunctions. Current studies also suggest social cognition impairments, but their results are inconsistent. This review offers the latest knowledge of social cognition in adults with Idiopathic generalised epilepsies. In addition, we provide an overview of the most frequently used assessment methods. We explain possible reasons for different outcomes and discuss future research perspectives.

Navigating Social Waters: Understanding Theory-of-Mind Challenges in Patients with Mesial Temporal Lobe Epilepsy

Background: Temporal lobe epilepsy is a common neurological disease that affects many areas of patients' lives, including social competence. The aim of the study was to assess theory of mind in patients with temporal lobe epilepsy and to investigate the demographic and clinical factors associated with this function. Methods: A total of 65 participants took part in the study, which included 44 patients with epilepsy and 21 demographically matched healthy individuals. The following neuropsychological tests were used to examine theory of mind: the Faux Pas Test, the Hinting Task, the Emotion Comprehension Test, and a cognitive function screen, the Montreal Cognitive Assessment. Results: Patients with epilepsy scored lower on all measures of the theory-of-mind tests. Moreover, in the clinical group, numerous moderate and strong correlations were found between the theory-of-mind tests and education, age at onset of epilepsy, lateralization of epileptic focus, cognitive status, and, to a lesser degree, number of anti-epileptic drugs, frequency of seizures, and age. In contrast, in the control group, significant correlations were found mostly between the theory-of-mind tests and sex, and, to a lesser degree, age. Education and cognitive functioning were not associated. Conclusions: Patients with epilepsy experience difficulties in theory of mind, which may have a negative impact on the quality of their social relationships. The level of theory-of-mind abilities correlates with particular clinical and demographic indicators. Recognizing these issues allows clinicians to implement tailored interventions, potentially improving patients' quality of life.

Dynamic facial emotion recognition and affective prosody recognition are associated in patients with temporal lobe epilepsy

Deficits in facial emotion recognition have frequently been established in temporal lobe epilepsy (TLE). However, static, rather than dynamic emotion recognition paradigms have been applied. Affective prosody has been insufficiently studied in TLE, and there is a lack of studies investigating associations between auditory and visual emotion recognition. We wished to investigate potential deficits in a dynamic morph task of facial emotion recognition and in an affective prosody recognition task, as well as associations between both tasks. 25 patients with TLE and 24 healthy controls (CG) performed a morph task with faces continuously changing in their emotional intensity. They had to press a button, as soon as they were able to recognize the emotion expressed, and label it accordingly. In the auditory task, subjects listened to neutral sentences spoken in varying emotional tones, and labeled the emotions. Correlation analyses were conducted across both tasks. TLE patients showed significantly reduced prosody recognition compared to CG, and in the morph task, there was a statistical trend towards significantly reduced performance for TLE. Recognition rates in both tasks were significantly associated. TLE patients show deficits in affective prosody recognition, and they may also be impaired in a morph task with dynamically changing facial expressions. Impairments in basic social-cognitive tasks in TLE seem to be modality-independent.

Facial affect recognition in context in adults with and without TBI

Introduction

Several studies have reported impaired emotion recognition in adults with traumatic brain injury (TBI), but studies have two major design features that limit application of results to real-world contexts: (1) participants choose from among lists of basic emotions, rather than generating emotion labels, and (2) images are typically presented in isolation rather than in context. To address these limitations, we created an open-labeling task with faces shown alone or in real-life scenes, to more closely approximate how adults with TBI label facial emotions beyond the lab.

Methods

Participants were 55 adults (29 female) with moderate to severe TBI and 55 uninjured comparison peers, individually matched for race, sex, and age. Participants viewed 60 photographs of faces, either alone or in the pictured person's real-life context, and were asked what that person was feeling. We calculated the percent of responses that were standard forced-choice-task options, and also used sentiment intensity analysis to compare verbal responses between the two groups. We tracked eye movements for a subset of participants, to explore whether gaze duration or number of fixations helped explain any group differences in labels.

Results

Over 50% of responses in both groups were words other than basic emotions on standard affect tasks, highlighting the importance of eliciting open-ended responses. Valence of labels by participants with TBI was attenuated relative to valence of Comparison group labels, i.e., TBI group responses were less positive to positive images and the same was true for negative images, although the TBI group responses had higher lexical diversity. There were no significant differences in gaze duration or number of fixations between groups.

Discussion

Results revealed qualitative differences in affect labels between adults with and without TBI that would not have emerged on standard forced-choice tasks. Verbal differences did not appear to be attributable to differences in gaze patterns, leaving open the question of mechanisms of atypical affect processing in adults with TBI.

Revisiting emotion recognition in different types of temporal lobe epilepsy: The influence of facial expression intensity

Temporal lobe epilepsy (TLE) can induce various difficulties in recognizing emotional facial expressions (EFE), particularly for negative valence emotions. However, these difficulties have not been systematically examined according to the localization of the epileptic focus. For this purpose, we used a forced-choice recognition task in which faces expressing fear, sadness, anger, disgust, surprise, or happiness were presented in different intensity levels from moderate to high intensity. The first objective of our study was to evaluate the impact of emotional intensity on the recognition of different categories of EFE in TLE patients compared to control participants. The second objective was to assess the effect of localizationof epileptic focus on the recognition of EFE in patients with medial temporal lobe epilepsy (MTLE) associated or not with hippocampal sclerosis (HS), or lateral temporal lobe epilepsy (LTLE). The results showed that the 272 TLE patients and the 68 control participants were not differently affected by the intensity of EFE. However, we obtained group differences within the clinical population when we took into account the localization of the temporal lobe epileptic focus. As predicted, TLE patients were impaired in recognizing fear and disgust relative to controls. Moreover, the scores of these patients varied according to the localization of the epileptic focus, but not according to the cerebral lateralization of TLE. The facial expression of fear was less well recognized by MTLE patients, with or without HS, and the expression of disgust was less well recognized by LTLE as well as MTLE without HS patients. Moreover, emotional intensity modulated differently the recognition of disgust and surprise of the three patient groups underlying the relevance of using moderate emotional intensity to distinguish the effect of epileptic focus localization. These findings should be taken into account for interpreting the emotional behaviors and deserve to befurther investigated before considering TLE surgical treatment or social cognition interventions in TLE patients.

Social Cognition in Temporal and Frontal Lobe Epilepsy: Systematic Review, Meta-analysis, and Clinical Recommendations

OBJECTIVE

Despite the importance of social cognitive functions to mental health and social adjustment, examination of these functions is absent in routine assessment of epilepsy patients. Thus, this review aims to provide a comprehensive overview of the literature on four major aspects of social cognition among temporal and frontal lobe epilepsy, which is a critical step toward designing new interventions.

METHOD

Papers from 1990 to 2021 were reviewed and examined for inclusion in this study. After the deduplication process, a systematic review and meta-analysis of 44 and 40 articles, respectively, involving 113 people with frontal lobe epilepsy and 1482 people with temporal lobe epilepsy were conducted.

RESULTS

Our results indicated that while patients with frontal or temporal lobe epilepsy have difficulties in all aspects of social cognition relative to nonclinical controls, the effect sizes were larger for theory of mind (g = .95), than for emotion recognition (g = .69) among temporal lobe epilepsy group. The frontal lobe epilepsy group exhibited significantly greater impairment in emotion recognition compared to temporal lobe. Additionally, people with right temporal lobe epilepsy (g =  1.10) performed more poorly than those with a left-sided (g = .90) seizure focus, specifically in the theory of mind domain.

CONCLUSIONS

These data point to a potentially important difference in the severity of deficits within the emotion recognition and theory of mind abilities depending on the laterlization of seizure side. We also suggest a guide for the assessment of impairments in social cognition that can be integrated into multidisciplinary clinical evaluation for people with epilepsy.

Verbosity with retelling: Narrative discourse production in temporal lobe epilepsy

To examine micro- and macrolinguistic underpinnings of circumstantiality in temporal lobe epilepsy (TLE), we examined the elicited narrative output of 15 individuals with TLE and 14 controls. To replicate and extend Field and colleagues' (2000) work, participants were asked to produce five immediately consecutive elicitations of an eight-frame cartoon "Cowboy Story" (Joanette et al., 1986). Following transcription and coding, detailed multi-level discourse analysis demonstrated a typical pattern of compression in controls. The narratives produced by individuals with TLE were less fluent, cohesive, and coherent across trials: producing fewer novel units and more repetitive and extraneous content. Significant group by trial interactions in sample length, spontaneous duration, and statements, were not explained by seizure burden, age, or lexical retrieval deficits. These findings suggest that they do not benefit from repeated engagement with a narrative in the same manner as controls. Disturbed social cognition and pragmatics in TLE might underpin communication inefficiencies.

Vague retellings of personal narratives in temporal lobe epilepsy

PURPOSE

Aside from deficits identified in single-word level retrieval, individuals with temporal lobe epilepsy (TLE) exhibit clinical oddities, such as circumstantiality in their language production. Circumstantiality refers to the use of language which is pedantic, repetitive, and overly detailed. This becomes particularly evident when elicitation tasks impose minimal structure, or when impersonal narratives are retold over consecutive occasions. Personal reminiscence is highly specific and localised in time, placing unique demands on cognitive-linguistic systems. It is hypothesised that the nature of this elicitation paradigm will produce a unique psycholinguistic phenotype in those with TLE. Among controls there is a compression of output for impersonal narratives, meaning that they use fewer words over less time and are more fluent. The opposite effect is observed when personal narratives are retold.

METHODS

To investigate the micro- and macrolinguistic processes underpinning personal discourse production in TLE, we examined the elicited language output of 15 surgically naïve individuals with TLE and 14 healthy controls. Participants were asked to recall and re-tell an autobiographical memory on four immediately consecutive occasions, representing an alternative unstructured elicitation. Following transcription and coding of output, a detailed multi-level discourse analysis of output volume, fluency, cohesion, and coherence was conducted.

RESULTS

As anticipated, a distinctly different pattern emerged in TLE when compared with controls who did not compress their output volume across repetitions but instead produced greater novelty, and a more coherent and refined account over time. Individuals with TLE consistently told a less distinct story across repetitions, with disturbances in fluency, cohesion, and coherence.

CONCLUSION

This reflects a reduced capacity to produce a coherent mental representation, in all likelihood related to the neurolinguistic demands of recalling and retelling specific personal events.

Toward social neuropsychology of epilepsy: a meta-analysis on social cognition in epilepsy phenotypes and a critical narrative review on assessment methods

Background

The aim of this review is to (a) characterize social cognition impairments in the domains of emotion recognition (ER) and theory of mind (ToM) in patients with epilepsy and (b) to review assessment tools with a focus on their validity and usability in clinical practice.

Methods

An electronic search for clinical studies investigating social cognition in epilepsy populations vs healthy control subjects (HC) yielded 53 studies for the meta-analysis and descriptive review.

Results

Results suggest that (1) social cognition is significantly impaired in patients with temporal lobe epilepsy (TLE), frontal lobe epilepsy (FLE) and patients with epilepsy not originating within the temporal or frontal lobes including idiopathic generalized epilepsies (eTLE/eFLE); (2) there is no significant difference between eTLE/eFLE and TLE regarding ER, while TLE and FLE patients perform worse than those with eTLE/eFLE, without significant differences between FLE and TLE regarding ToM ability. A descriptive analysis of the most commonly used assessment tools and stimulus material in this field revealed a lack of ecological validity, usability, and economic viability for everyday clinical practice.

Conclusions

Our meta-analysis shows that patients with epilepsy are at a significantly increased risk of deficits in social cognition. However, the underlying multifactorial mechanisms remain unclear. Future research should therefore specifically address the impairment of processing and methodological problems of testing.

Face-induced gamma oscillations and event-related potentials in patients with epilepsy: an intracranial EEG study

Background

To examine the pathological effect of a mesial temporal seizure onset zone (SOZ) on local and inter-regional response to faces in the amygdala and other structures of the temporal lobe.

Methods

Intracranial EEG data was obtained from the amygdala, hippocampus, fusiform gyrus and parahippocampal gyrus of nine patients with drug-refractory epilepsy during visual stimulation with faces and mosaics. We analyzed event-related potentials (ERP), gamma frequency power, phase-amplitude coupling and phase-slope-index and compared the results between patients with versus without a mesial temporal SOZ.

Results

In the amygdala and fusiform gyrus, faces triggered higher ERP amplitudes compared to mosaics in both patient groups and higher gamma power in patients without a mesial temporal SOZ. In the hippocampus, famous faces triggered higher gamma power for both groups combined but did not affect ERPs in either group. The differentiated ERP response to famous faces in the parahippocampal gyrus was more pronounced in patients without a mesial temporal SOZ. Phase-amplitude coupling and phase-slope-index results yielded bidirectional modulation between amygdala and fusiform gyrus, and predominately unidirectional modulation between parahippocampal gyrus and hippocampus.

Conclusions

A mesial temporal SOZ was associated with an impaired response to faces in the amygdala, fusiform gyrus and parahippocampal gyrus in our patients. Compared to this, the response to faces in the hippocampus was impaired in patients with, as well as without, a mesial temporal SOZ. Our results support existing evidence for face processing deficits in patients with a mesial temporal SOZ and suggest the pathological effect of a mesial temporal SOZ on the amygdala to play a pivotal role in this matter in particular.

Emotional Word Processing in Patients With Juvenile Myoclonic Epilepsy

Objective

According to Panksepp's hierarchical emotion model, emotion processing relies on three functionally and neuroanatomically distinct levels. These levels comprise subcortical networks (primary level), the limbic system (secondary level), and the neocortex (tertiary level) and are suggested to serve differential emotional processing. We aimed to validate and extend previous evidence of discrete and dimensional emotion processing in patient with juvenile myoclonic epilepsy (JME).

Methods

We recorded brain activity of patients with JME and healthy controls in response to lexical decisions to words reflecting the discrete emotion fear and the affective dimension negativity previously suggested to rely on different brain regions and to reflect different levels of processing. In all study participants, we tested verbal cognitive functions, as well as the relationship of psychiatric conditions, seizure types and duration of epilepsy and emotional word processing.

Results

In support of the hierarchical emotion model, we found an interaction of discrete emotion and affective dimensional processing in the right amygdala likely to reflect secondary level processing. Brain activity related to affective dimensional processing was found in the right inferior frontal gyrus and is suggested to reflect tertiary level processing. Psychiatric conditions, type of seizure nor mono- vs. polytherapy and duration of epilepsy within patients did not have any effect on the processing of emotional words. In addition, no differences in brain activity or response times between patients and controls were observed, despite neuropsychological testing revealed slightly decreased verbal intelligence, verbal fluency and reading speed in patients with JME.

Significance

These results were interpreted to be in line with the hierarchical emotion model and to highlight the amygdala's role in processing biologically relevant stimuli, as well as to suggest a semantic foundation of affective dimensional processing in prefrontal cortex. A lack of differences in brain activity of patients with JME and healthy controls in response to the emotional content of words could point to unaffected implicit emotion processing in patients with JME.

Functional patterns of neural activation during vocal emotion recognition in youth with and without refractory epilepsy

Epilepsy has been associated with deficits in the social cognitive ability to decode others' nonverbal cues to infer their emotional intent (emotion recognition). Studies have begun to identify potential neural correlates of these deficits, but have focused primarily on one type of nonverbal cue (facial expressions) to the detriment of other crucial social signals that inform the tenor of social interactions (e.g., tone of voice). Less is known about how individuals with epilepsy process these forms of social stimuli, with a particular gap in knowledge about representation of vocal cues in the developing brain. The current study compared vocal emotion recognition skills and functional patterns of neural activation to emotional voices in youth with and without refractory focal epilepsy. We made novel use of inter-subject pattern analysis to determine brain areas in which activation to emotional voices was predictive of epilepsy status. Results indicated that youth with epilepsy were comparatively less able to infer emotional intent in vocal expressions than their typically developing peers. Activation to vocal emotional expressions in regions of the mentalizing and/or default mode network (e.g., right temporo-parietal junction, right hippocampus, right medial prefrontal cortex, among others) differentiated youth with and without epilepsy. These results are consistent with emerging evidence that pediatric epilepsy is associated with altered function in neural networks subserving social cognitive abilities. Our results contribute to ongoing efforts to understand the neural markers of social cognitive deficits in pediatric epilepsy, in order to better tailor and funnel interventions to this group of youth at risk for poor social outcomes.

Theory of mind and facial emotion recognition in adults with temporal lobe epilepsy: A meta-analysis

BACKGROUND

Mounting studies have investigated impairments in social cognitive domains (including theory of mind [ToM] and facial emotion recognition [FER] in adult patients with temporal lobe epilepsy (TLE). However, to date, inconsistent findings remain.

METHODS

A search of PubMed, Web of Science, and Embase databases was conducted until December 2021. Hedges g effect sizes were computed with a random-effects model. Meta-regressions were used to assess the potential confounding factors of between-study variability in effect sizes.

RESULTS

The meta-analysis included 41 studies, with a combined sample of 1,749 adult patients with TLE and 1,324 healthy controls (HCs). Relative to HCs, adult patients with TLE showed large impairments in ToM (g = -0.92) and cognitive ToM (g = -0.92), followed by medium impairments in affective ToM (g = -0.79) and FER (g = -0.77). Besides, no (statistically) significant differences were observed between the magnitude of social cognition impairment in adult with TLE who underwent and those who did not undergo epilepsy surgery. Meta-regressions exhibited that greater severity of executive functioning was associated with more severe ToM defects, and older age was associated with more severe FER defects.

CONCLUSIONS

Results of this meta-analysis suggest that adult patients with TLE show differential impairments in the core aspects of social cognitive domains (including ToM and FER), which may help in planning individualized treatment with appropriate cognitive and behavioral interventions.

Affective Empathy, Theory of Mind and Social Functioning in Patients With Focal Epilepsy

OBJECTIVE

Social cognition comprises basic and more complex functions, such as theory of mind (ToM) and affective empathy. Although everyday social interactions may be impaired if such higher-order social cognitive functions are compromised, associations between social functioning and social cognition in people with focal epilepsy (PWFE) are still poorly understood. We used a novel, naturalistic approach to investigate ToM in PWFE by applying the Movie for the Assessment of Social Cognition (MASC). Furthermore, we studied affective empathy, the relationship between social cognitive parameters and measures of social functioning, as well as between epilepsy focus and ToM.

METHODS

Thirty patients with either temporal (TLE) or frontal lobe epilepsy (FLE) were compared to 29 healthy control subjects (HC). In addition to the MASC, we applied questionnaire measures assessing empathy and everyday social functioning.

RESULTS

PWFE, especially with FLE, performed significantly worse than HC on the MASC. Perceived social integration and social activities, but not affective empathy, were reduced in PWFE. Regression analyses revealed associations between perceived social integration, clinical group status, affective empathy and ToM.

CONCLUSION

PWFE displayed ToM deficits during a naturalistic task, whereas affective empathy was unimpaired. FLE may be associated with especially compromised ToM performance. Social cognition and social functioning appear to be interrelated in PWFE, whose self-perceived levels of social integration and social activities are lower than those of HC. More research into the association between social cognition and social functioning in PWFE is needed, in order to develop tailored intervention programs for these patients.

The effect of facial expression intensity on emotion recognition and psychosocial performance in patients with frontal or temporal lobe epilepsy

PURPOSE

No studies have examined the relationship between the intensity of facial emotion expression and theory of mind (ToM) ability in people with epilepsy. This study aimed to explore facial emotion recognition in a group of patients with frontal (FLE) or temporal lobe epilepsy (TLE) and its relationship with the intensities of perceived facial emotion expressions, ToM, and social functioning.

METHODS

Twenty-six patients with FLE or TLE and 30 matched controls were included in the study. All participants completed the facial emotion recognition test, Faux Pas Recognition (FPR) test measuring advanced ToM, Symptom Checklist-90-Revised, Social and Occupational Functioning Scale for Epilepsy (SOFSE), and background neuropsychological tests.

RESULTS

The patient group was significantly worse than the control group in recognizing facial expressions of negative emotions, particularly for medium-intensity facial expression of fear. There was no significant difference between the groups in recognizing high-intensity fear facial expressions. The scores of FPR (overall and affective ToMs) in the patient group were significantly lower than those in the control group. Additionally, the facial emotion recognition was significantly associated with the total score of FPR, and the FPR total score remarkably correlated with the Communication subscale score of the SOFSE.

CONCLUSIONS

Patients with FLE or TLE had impaired ability to recognize medium-intensity facial expressions of fear. Moreover, patients' ToM deficit significantly correlated not only with their emotion recognition problem but also with their social-communicative competence. Nevertheless, we also found that increasing the intensity of expression can improve the accuracy of emotion recognition in patients with epilepsy. These findings may provide considerations for further longitudinal studies and interventions on the social difficulties of people with epilepsy.

Theory of Mind and Empathy in Adults With Epilepsy: A Meta-Analysis

Mounting evidence suggests that social cognitive abilities [including theory of mind (ToM) and empathy] are impaired in adult patients with epilepsy. Although the deficits in overall ToM in epilepsy have been documented well, the effects of epilepsy on empathic ability and specific subcomponents of ToM remain unclear. The primary aim of this study was to provide the first meta-analytic integration of ToM and empathy in adult patients with epilepsy, and to decompose these constructs to clearly differentiate their distinct (cognitive ToM and affective empathy) and overlapping (affective ToM/cognitive empathy) components. This meta-analysis included 28 studies. Adult patients with temporal lobe epilepsy (TLE) and frontal lobe epilepsy (FLE) showed impairments in cognitive ToM and affective ToM/cognitive empathy compared to the healthy controls (HCs); no group differences were identified for affective empathy. Besides, cognitive ToM was impaired in adult patients with idiopathic generalized epilepsy (IGE) and focal seizures (caused by epileptogenic foci) outside the temporal and frontal lobes (extra-TLE/FLE) and no group differences were evident for affective ToM/cognitive empathy compared to the HCs. Moreover, relative to the HCs, no group differences were identified for affective empathy in adult patients with IGE. Additionally, no (statistically) significant difference was observed between the magnitude of ToM/empathy impairment in adult patients who underwent and those who did not undergo epilepsy surgery. These quantitative findings suggest differential impairment of the core aspects of social cognitive processing in adult patients with epilepsy, which may contribute to the development of structured cognitive interventions (i.e., social cognitive training) for adult patients with epilepsy.

An Encounter With the Other: A Thematic and Content Analysis of DMT Experiences From a Naturalistic Field Study

Introduction: N,N-dimethyltryptamine (DMT) is an endogenous serotonergic psychedelic capable of producing radical shifts in conscious experience. Increasing trends in its use, as well as new trials administering DMT to patients, indicate the growing importance of a thorough elucidation of the qualitative content, over and above structure, which the drug occasions. This is particularly in light of the hyper-real, otherworldly, and often ontologically challenging yet potentially transformative, nature of the experience, not least encounters with apparently non-self social agents. Laboratory studies have been limited by clinical setting and lacking qualitative analyses of experiential content, while online surveys' limitations lie in retrospective design, uncontrolled use, and both of which not guaranteeing 'breakthrough' experiences, i.e., producing very strong psychoactive effects. Methods: We report on the first naturalistic field study of DMT use including its qualitative analysis. Screened, healthy, anonymised and experienced DMT users were observed during their non-clinical use of the drug at home (40-75 mg inhaled). In-depth semi-structured interviews (inspired by the micro-phenomenological technique) were employed immediately after their experience. This paper reports on the thematic analysis of one major domain of the breakthrough experiences elicited, the 'other'. Thirty-six post-DMT experience interviews with mostly Caucasian (83%) males (eight female) of average 37 years were predominantly inductively coded. Results: Invariably, profound and highly intense experiences occurred. The first overarching category comprised the encounter with other 'beings' (94% of reports), encompassing super-ordinate themes including the entities' role, appearance, demeanour, communication and interaction; while the second overarching category comprised experiences of emerging into other 'worlds' (100% of reports), encompassing super-ordinate themes of the scene, the contents and quality of the immersive spaces. Many further mid-level themes and subthemes also illuminate the rich content of the DMT experience. Discussion: The present study provides a systematic and in-depth analysis of the nuanced content of the otherworldly encounter within the breakthrough DMT experience, as well as elaborating on the resonances both with previous DMT studies focusing on entity encounters and other types of extraordinary experiences entailing such encounters. These include the alien abduction, folkloric, shamanic and near-death experience. Putative neural mechanisms of these features of the DMT experience and its promise as a psychotherapeutic agent are discussed in light of such findings.

Emotion recognition and theory of mind after temporal lobe epilepsy surgery: A systematic review

In order to navigate in our complex social world successfully, it is crucial to maintain and practice cognitive skills that are dedicated to adaptive social functioning. Emerging evidence suggests that besides deficits in declarative memory, executive functions, and language, impairments in social cognition (SC, e.g., emotion recognition, theory of mind) are also present in temporal lobe epilepsy (TLE). The organic and psycho-social consequences of epilepsy surgery might have additional implications regarding this deficit. Here we qualitatively synthesize longitudinal and cross-sectional findings on SC after TLE surgery. A literature search using PubMed and Scopus identified 275 potential articles. Studies were eligible if they (1) included patients with a diagnosis of TLE, (2) included a healthy comparison group, (3) reported original research, (4) were published in peer-reviewed journals and in English language, (5) reported the intervention of epilepsy surgery. Articles that (1) were case studies, (2) did not focus on SC abilities, (3) used interviews or self-report questionnaires to examine SC functions were excluded. A total of 16 original studies assessing emotion recognition (ER) and/or theory of mind (ToM) matched our criteria. The literature suggests that neither ER nor ToM abilities change after surgery: post-surgery patients show similar impairment patterns to pre-surgery patients. Nevertheless, individual improvement or decline could be masked by group comparisons and results should be considered in light of methodological heterogeneity among studies.

Theory of mind and its relationship with alexithymia and quality of life in patients with psychogenic nonepileptic seizures: Comparisons with generalised epilepsy and healthy controls

OBJECTIVE

Psychogenic nonepileptic seizures (PNES) are associated with high alexithymia, social cognition problems and low quality of life (QoL). Theory of Mind (ToM) has been studied in several conditions as a significant predictor of QoL. We aimed to assess the relationship between ToM abilities, alexithymia and subjective QoL in PNES patients and compare with generalised epilepsy (ES) patients and healthy controls.

METHOD

Patients with PNES (n = 28), ES (n = 28) and healthy volunteers (n = 28) were evaluated for alexithymia and quality of life (QoL) with Toronto Alexithymia Scale-20 (TAS-20) and Short Form-36 (SF-36). Reading the Mind in the Eyes test was used for assessment of affective ToM and Hinting Task and Strange Stories tests for cognitive ToM abilities.

RESULTS

Analyses revealed lower SF-36 scores and poorer ToM performance in the PNES group compared to healthy group and poorer cognitive ToM performance than ES group. Cognitive ToM performance was inversely correlated with TAS-20 "difficulty identifying feelings" subscale and "physical functioning" subscale of SF-36 in the PNES group.

CONCLUSION

These results are consistent with previous research on PNES and other somatoform disorders and suggest that PNES is associated with impaired ToM task performance. ToM task performance might be related to specific aspects of alexithymia and QoL.

The Impact of Social Cognition on the Real-Life of People with Epilepsy

Background. Previous research has demonstrated the impairment of social cognition (SC) in people with epilepsy. It is associated with worse social functioning and quality of life; however, the influence on real-life outcomes is unknown. The purpose of this study was to investigate how SC is associated with epilepsy variables and real-life outcomes (education, employment and relationships) among patients with epilepsy (PWE). Methods. Eighty-one PWE completed tasks of theory of mind (ToM) (faux pas recognition (FPRT) and Happé Strange Stories test (HST)) and emotion recognition (ER) (Reading of the Mind in the Eyes (RMET)). Variables reflecting their education, employment and relationship status were treated as endpoints in search of association with SC. Data from a matched group (n = 30) of healthy controls (HCs) were used for comparison of ToM abilities. Results. ToM scores were lower among PWE as compared to HCs (U = 1816.0, p < 0.0001 (HST), U = 1564.5, p = 0.020 (FPRT)). All SC tests were associated with the level of education (OR = 1.22, 95% confidence interval (CI) = 1.09 to 1.36 (RMET), OR = 1.20, 95% CI = 1.02 to 1.40 (HST), OR = 0.93, 95% CI = 0.87 to 1.00 (FPRT)). The results of ToM and ER testing were not associated with employment (χ² = 33.423, p < 0.0001) if adjusted for the level of education (B = 0.804, OR = 2.23 (95% CI = 1.33 to 3.76), p = 0.002). SC abilities did not differ between PWE who were single and those in a relationship (U = 858.5, p = 0.541 (HST)), t= −1.236, p = 0.220 (RMET), U = 909.5, p = 0.271 (FPRT)). Conclusion. Better social cognition skills are linked to a higher level of education among PWE. SC probably has less influence on professional achievements and interpersonal relationships.

Social brain networks: Resting-state and task-based connectivity in youth with and without epilepsy

Individuals with epilepsy often experience social difficulties and deficits in social cognition. It remains unknown how disruptions to neural networks underlying such skills may contribute to this clinical phenotype. The current study compared the organization of relevant brain circuits-the "mentalizing network" and a salience-related network centered on the amygdala-in youth with and without epilepsy. Functional connectivity between the nodes of these networks was assessed, both at rest and during engagement in a social cognitive task (facial emotion recognition), using functional magnetic resonance imaging. There were no group differences in resting-state connectivity within either neural network. In contrast, youth with epilepsy showed comparatively lower connectivity between the left posterior superior temporal sulcus and the medial prefrontal cortex-but greater connectivity within the left temporal lobe-when viewing faces in the task. These findings suggest that the organization of a mentalizing network underpinning social cognition may be disrupted in youth with epilepsy, though differences in connectivity within this circuit may shift depending on task demands. Our results highlight the importance of considering functional task-based engagement of neural systems in characterizations of network dysfunction in epilepsy.

Cognitive and behavioral profiles of pediatric surgical candidates with frontal and temporal lobe epilepsy

BACKGROUND

We aimed to prospectively analyze memory and executive and social cognitive functioning in patients with drug-resistant frontal lobe epilepsy (FLE) and temporal lobe epilepsy (TLE) with focal lesions and isolate the impact of intellectual ability on specific deficits.

METHODS

A neuropsychological evaluation was performed in 23 children with FLE, 22 children with TLE, and 36 healthy pediatric controls (HCs). Patients in the epilepsy groups had a range of lesions, including low-grade epilepsy-associated tumors (LEAT), focal cortical dysplasia (FCD) type II, and mesial temporal sclerosis (MS).

RESULTS

There were no significant differences between children with FLE and TLE regarding memory, executive, or social cognitive functioning. General Ability Index (GAI) was a predictor of memory, executive function, and social cognition scores and was influenced by age at onset, duration of epilepsy, and number of antiepileptic drugs (AEDs) prescribed at the time of assessment. Working Memory Index scores of patients with TLE, which measure verbal mnesic processing, were significantly lower than those of HCs and patients with TLE. The greatest differences in both clinical groups compared to HCs were recorded in cognitive executive functions, and patients with FLE had lower scores in this domain. Regarding behavioral executive functions, patients with TLE presented impaired emotional control and impulse inhibition and patients with FLE exhibited decreased flexibility.

CONCLUSION

Consistent with previous research, our findings provide further detailed evidence of small differences in cognitive performance among children with FLE and TLE. These differences emerge on analysis of the factors with which deficits are associated.

Single-word, sentence, and discourse comprehension in individuals with temporal lobe epilepsy

The purpose of this study was to systematically investigate language comprehension in individuals with left and right temporal lobe epilepsy (TLE) at different language levels - single word (noun and verb), sentence, and discourse. Neither of the groups with TLE showed difficulties with noun comprehension, whereas verb comprehension performance was significantly lower in individuals with left, but not right TLE as compared to healthy controls. In contrast, sentence and discourse comprehension was overall impaired, irrespective of the lateralization of the epileptogenic focus. Education level and age at seizure onset were also found correlating with language comprehension in our tested cohort. The results, firstly, confirm that the verb comprehension task is more sensitive for assessment of single-word comprehension in individuals with TLE. Secondly, they indicate that language comprehension in left and right TLE is mostly impaired at the sentence and discourse levels, which may be associated with low working memory capacities.

Social cognition in an adult epilepsy patient with developmental amnesia

Reports on social cognition in patients with developmental amnesia resulting from bilateral hippocampal lesions are rare, although the link between social cognition and temporal lobe structures is well established. We present the case of a 23-year-old male epilepsy patient, BM, with developmental amnesia due to perinatal cerebral hypoxia. The patient was examined with neuroimaging and neuropsychological methods and compared to IQ-matched patients with epilepsy to control for effects of epilepsy. In addition, we used a test battery that evaluates emotion recognition and theory of mind to study his social cognition abilities. Structural high-resolution magnetic resonance imaging showed bilateral hippocampal atrophy. The comparison to controls showed that, in addition to the well-documented memory disorders in developmental amnesia, BM showed remarkable deficits in 9 out of 17 social cognitive tasks assessing emotion recognition and theory of mind. In contrast, BM's performance on tasks of executive functions was largely preserved. The relevance of deficits in social cognition for patients with developmental amnesia is discussed.

Social cognition in epilepsy: State of the art and perspectives

INTRODUCTION

The neuropsychology of epilepsy has been a major area of study for almost a century and cognitive impairments are an integral part of the new definition of epilepsy. Among such impairments, social cognition (SC) dysfunctions are of relatively recent interest. SC abilities refer to the body of knowledge and processes involved in establishing satisfying and appropriate social interactions. In particular, they allow the recognition of emotions in others, emotional experiences which are suitably adapted to social situations, and the ability to infer mental states in oneself and others.

METHODS

An overeview was conducted of the available data within the literature, with the objective of presenting the SC disorders associated with certain types of epilepsy and the possible risk factors already explored i.e., localisation of epileptic focus, age of onset/duration of the disease, and effects of treatments including surgery. Studies investigating the potential repercussions of these disorders on patients' daily life have also been included.

RESULTS

Social cognition disorders are an integral part of the cognitive disorders traditionally described in epilepsy. Indeed, a growing number of studies highlight the increased prevalence of SC disorders in various domains, and some patients appear to be more at risk than others. These disorders could be a major determining factor in the deterioration of patients' quality of life (QOL), particularly patients' support and social integration. This highlights the importance of assessing and managing these disorders in patients with epilepsy (PWE). Perspectives in the field of research and clinical practice are also evoked, such as exploring the links between disruptions in SC abilities and treatments, or developing specific tools for assessment and rehabilitation within the context of epilepsy.

Patterns of impaired social cognition in children and adolescents with epilepsy: The borders between different epilepsy phenotypes

Over the past decade, a growing number of studies have shown that children and adolescents with focal and generalized epilepsies have marked impairments in social cognition, including deficits in facial emotion perception (FEP) and Theory of Mind (ToM). At present, it remains unclear whether FEP and ToM impairments are comparable in children with focal and generalized epilepsies or whether distinct syndrome-specific deficits have emerged. This question of whether unique or overlapping social cognitive profiles exist in epilepsy is of interest, given that the revised International League Against Epilepsy (ILAE) classification guidelines propose that seizures arise from a diseased network (i.e., network account), rather than being confined to discrete regions near the site of seizure foci (i.e., localization account). The purpose of this review was as follows: (1) to summarize studies examining FEP and ToM in pediatric patients with epilepsy, (2) to examine epilepsy and psychosocial correlates of these difficulties, and (3) to determine whether patterns of sociocognitive impairment better support a localization or neural network account of epilepsy. Twelve studies were reviewed examining FEP (N = 5) and/or ToM (N = 8). Findings revealed significant FEP and ToM impairments across the studied subgroups with epilepsy, which did not differ between children with generalized and focal (localization-related) epilepsies nor among children with different subtypes of localization-related epilepsy. Similarly, other epilepsy variables (i.e., seizure frequency, side of seizure focus, number of antiepileptic drugs (AEDs) or surgical status) were not related to FEP or ToM, with the exception of younger age at seizure onset and longer duration of epilepsy. Several studies documented a significant relationship between impaired ToM and reduced social competence in pediatric patients with epilepsy, whereas evidence for a relationship between FEP and psychosocial functioning is currently weak. In conclusion, findings suggest that social cognitive impairments represent a shared feature of epilepsy in childhood. The results support a neural network account of epilepsy, in which a shared neural network of dysfunction may be underlying social cognitive deficits in this group. Further research is needed to examine the functional correlates of social cognitive impairments, as well as to evaluate screening tools and treatment methods to identify and address significant social and emotional difficulties in this patient group. This article is part of the Special Issue "Epilepsy and social cognition across the lifespan".

Social cognition and psychopathology in childhood and adolescence

There is a substantial body of research on social cognition in adults with epilepsy, and in broad categories such as focal and generalized epilepsies, but much less has been written about social cognition in children with epilepsy (CWE), and in childhood-onset epilepsy syndromes specifically. In several of these syndromes, autism spectrum disorder (ASD) and attention-deficit hyperactivity disorder (ADHD), two disorders with social cognitive impairments, are reported. There is strong evidence for social cognitive deficits in juvenile myoclonic epilepsy (JME). There is also a considerable amount of evidence for such deficits in a number of syndromes that may be associated with ASD or ADHD, including West syndrome (WS), Dravet syndrome (DS), and the Landau-Kleffner syndrome (LKS). However, the evidence is of variable quality and incomplete across the range of childhood epilepsy syndromes. In some syndromes, childhood epilepsy substantially increases the risk of severe social cognitive impairment, which may persist after the seizures remit. This paper presents an overview of current research on social cognition in childhood epilepsy, with a particular focus on syndromes with a high prevalence of autistic and behavioral comorbidities. Social cognitive impairments represent a considerable additional challenge for patients and caregivers. Early diagnosis and intervention might significantly improve long-term social cognitive outcomes, highlighting the need for greater awareness among clinicians of this important topic. This article is part of the Special Issue "Epilepsy and social cognition across the lifespan".

Social cognition in idiopathic generalized epilepsies and potential neuroanatomical correlates

Social cognition allows us to elaborate mental representations of social relationships and use them appropriately in a social environment. One of its main attributes is the so-called Theory of Mind (ToM), which consists of the ability to attribute beliefs, intentions, emotions, and feelings to self and others. Investigating social cognition may help understand the poor social outcome often experienced by persons with Idiopathic Generalized Epilepsies (IGE), who otherwise present with normal intelligence. In recent years, several studies have addressed social cognition in subjects with focal epilepsies, while literature on social cognition in IGE is scarce, and findings are often conflicting. Some studies on samples of patients with mixed IGE showed difficulties in emotion attribution tasks, which were not replicated in a homogeneous population of patients with Juvenile Myoclonic Epilepsy alone. Impairment of higher order social skills, such as those assessed by Strange Stories Test and Faux Pas Tasks, were consistently found by different studies on mixed IGE, suggesting that this may be a more distinctive IGE-associated trait, irrespective of the specific syndrome subtype. Though an interplay between social cognition and executive functions (EF) was suggested by several authors, and their simultaneous impairment was shown in several epilepsy syndromes including IGE, no formal correlations among the two domains were identified in most studies. People with IGE exhibit subtle brain structural alterations in areas potentially involved in sociocognitive functional networks, including mesial prefrontal and temporoparietal cortices, which may relate to impairment in social cognition. Heterogeneity in patient samples, mostly consisting of groups with mixed IGE, and lack of analyses in specific IGE subsyndromes, represent evident limitations of the current literature. Larger studies, focusing on specific subsyndromes and implementing standardized test batteries, will improve our understanding of sociocognitive processing in IGE. Concomitant high-resolution structural and functional neuroimaging may aid the identification of its neural correlates. This article is part of the Special Issue "Epilepsy and social cognition across the lifespan".

Social cognition, psychiatric comorbidities, and quality of life in adults with epilepsy

Deficits in social cognition are an increasingly recognized complication of epilepsy and contribute to the deficits in social functioning and well-being experienced by patients with epilepsy. Although there has been an increase in studies exploring the measurement and biology of social cognition in patients with epilepsy, there are relatively few examining its clinical implications. Those studies that have been published highlight that social cognitive deficits contribute to impaired quality of life (QoL) in patients with epilepsy, independent of other comorbidities such as depression, anxiety, seizure frequency, and impairment in other cognitive domains. This raises the possibility of novel therapeutic approaches to improving the social well-being of patients with epilepsy.

Dynamics and diversity of heart rate responses to a disaster motion picture

Emotions are dynamic neuropsychophysiological processes that guide behavior and serve as crucial signals during social interactions. Measuring their highly individual temporal dynamics is an unresolved challenge, but the coupling of autonomic and central nervous processes offers a promising approach. We present a feasible approach to study changes in heart rate during emotions and demonstrate a link to empathy. We investigated the interindividual similarity and temporal dynamics of heart rate responses to an emotive motion picture. Forty healthy participants watched "The Impossible" (109 min; Hermida Muñiz et al., 2012) while their heart rate was recorded. Interindividual concordance of heart rate responses was analysed using agglomerative hierarchical clustering analyses to distinguish response patterns throughout the movie and during six highly emotive scenes. This revealed multiple response patterns during emotive scenes. Second, we analysed how changes in heart rate are linked to self-reported empathy. We found that the extent of changes in heart rate is positively linked to trait and state empathy. During specific scenes, this relationship was only visible when individuals with homogeneous heart rate response patterns were observed, but not across discordant response patterns. In conclusion, our results demonstrate that heart rate responses to complex social stimuli are not uniform. Therefore, research should favour statistical procedures with the potential to detect interindividual differences. The approach presented in our study allows us to depict interindividual similarity and diversity in emotional autonomic responses and emphasizes the key role of empathy in emotional experiences.

Epilepsy, language, and social skills

Language and social skills are essential for intrapersonal and interpersonal functioning and quality of life. Since epilepsy impacts these important domains of individuals' functioning, understanding the psychosocial and biological factors involved in the relationship among epilepsy, language, and social skills has important theoretical and clinical implications. This review first describes the psychosocial and biological factors involved in the association between language and social behavior in children and in adults and their relevance for epilepsy. It reviews the findings of studies of social skills and the few studies conducted on the inter-relationship of language and social skills in pediatric and adult epilepsy. The paper concludes with suggested future research and clinical directions that will enhance early identification and treatment of epilepsy patients at risk for impaired language and social skills.

Altered upright face recognition and presence of face inversion effect in temporal lobe epilepsy: An event-related potential study

AIM

Facial recognition can be assessed by examining an event-related potential component, namely the N170. The amplitude of the N170 is larger in response to inverted faces than to upright faces. To examine facial processing in patients with temporal lobe epilepsy (TLE), we investigated the amplitude of the N170, the face inversion effect, and the association between social functioning and face-specific configuration processing.

METHODS

Sixteen patients with TLE and 17 normal controls (NC) participated in this study. Event-related potentials in response to upright or inverted neutral faces and bicycles were recorded. Social functioning was assessed by the socioeconomic status of the participants using the 5-point Hollingshead-Redlich Scale.

RESULTS

Compared with NC, patients with TLE had decreased N170 amplitudes. The inversion effect was observed for face stimuli in both groups; however, no inversion effect was observed for bicycle stimuli. Additionally, in TLE patients, but not in NC, socioeconomic status was significantly correlated with the N170 amplitudes in response to upright faces.

CONCLUSION

In a social context, upright faces are processed as a whole. This process is impaired in TLE. Conversely, inverted faces are processed analytically. This function is normal in TLE. Abnormal face-specific configuration processing may contribute to lower social functioning in TLE.

Psychiatric Assessment in Patients with Mild Temporal Lobe Epilepsy

Objectives

The findings of previous studies focused on personality disorders in epileptic patients are difficult to interpret due to nonhomogeneous samples and noncomparable methods. Here, we aimed at studying the personality profile in patients with mild temporal lobe epilepsy (mTLE) with psychiatric comorbidity.

Materials and Methods

Thirty-five patients with mTLE (22 males, mean age 40.7 ± 12.1) underwent awake and sleep EEG, 3T brain MRI, and an extensive standardized diagnostic neuropsychiatric battery: Temperament and Character Inventory-Revised (TCI-R), Beck Depression Inventory-2, and State-Trait Anxiety Inventory. Drug history was collected in detail. Hierarchical Cluster Analysis was performed on TCI-R data, while all other clinical and psychological variables were compared across the resulting clusters.

Results

Scores of Harm Avoidance (HA), Reward Dependence (RD), Persistence (P), Cooperativeness (C), and Self-Transcendence (ST) allowed the identification of two clusters, describing different personality subtypes. Cluster 1 was characterized by an early onset, more severe anxiety traits, and combined drug therapy (antiepileptic drug and Benzodiazepine/Selective Serotonin Reuptake Inhibitors) compared to Cluster 2.

Conclusions

Our findings suggest that different personality traits may play a role in determining the clinical outcome in patients with mTLE. Specifically, lower scores of HA, RD, P, C, and ST were associated with worse clinical outcome. Thus, personality assessment could serve as an early indicator of greater disease severity, improving the management of mTLE.

Theory of Mind impairment in focal versus generalized epilepsy

Theory of Mind (ToM) is a critical component of social cognition, and thus, its impairment may adversely affect social functioning and quality of life. Recent evidence has suggested that it is impaired in epilepsy. What is not clear, however, is whether it is related to particular types of epilepsy or other factors. We undertook the present study to explore ToM in patients with focal versus those with generalized epilepsy, the particular pattern of ToM deficits, and the potential influence of antiepileptic medication load. Our sample included 149 adults: 79 patients with epilepsy (34 with generalized epilepsy and 45 with focal epilepsy) and 70 healthy controls. Theory of Mind tasks included a) comprehension of hinting, b) comprehension of sarcasm and metaphor, c) comprehension of false beliefs and deception, d) recognition of faux pas, and e) a visual ToM task in cartoon form. We found significant ToM impairment in the group with focal epilepsy relative to the performance of both the healthy group and the group with generalized epilepsy on all tasks, with the exception of faux pas, on which the group with generalized epilepsy also performed more poorly than the healthy group. Additionally, early age at seizure onset, but not antiepileptic drug (AED) load, was associated with ToM performance. Our findings suggest that focal temporal and frontal lobe, but not generalized, epilepsies were associated with impaired ToM. This may reflect the neuroanatomical abnormalities in the relevant neuronal networks and may have implications for differential cognitive-behavioral interventions based on epilepsy type.

Affective, neurocognitive and psychosocial disorders associated with traumatic brain injury and post-traumatic epilepsy

Survivors of traumatic brain injury (TBI) often develop chronic neurological, neurocognitive, psychological, and psychosocial deficits that can have a profound impact on an individual's wellbeing and quality of life. TBI is also a common cause of acquired epilepsy, which is itself associated with significant behavioral morbidity. This review considers the clinical and preclinical evidence that post-traumatic epilepsy (PTE) acts as a 'second-hit' insult to worsen chronic behavioral outcomes for brain-injured patients, across the domains of emotional, cognitive, and psychosocial functioning. Surprisingly, few well-designed studies have specifically examined the relationship between seizures and behavioral outcomes after TBI. The complex mechanisms underlying these comorbidities remain incompletely understood, although many of the biological processes that precipitate seizure occurrence and epileptogenesis may also contribute to the development of chronic behavioral deficits. Further, the relationship between PTE and behavioral dysfunction is increasingly recognized to be a bidirectional one, whereby premorbid conditions are a risk factor for PTE. Clinical studies in this arena are often challenged by the confounding effects of anti-seizure medications, while preclinical studies have rarely examined an adequately extended time course to fully capture the time course of epilepsy development after a TBI. To drive the field forward towards improved treatment strategies, it is imperative that both seizures and neurobehavioral outcomes are assessed in parallel after TBI, both in patient populations and preclinical models.

Cognition in epilepsy: current clinical issues of interest

PURPOSE OF REVIEW

This review provides an update and summary of recent neuropsychological findings in epilepsy focusing on three major clinical topics among the many developments in the field. We will critically outline the current state with regard to cognition in new-onset epilepsies, social cognition in epilepsy, and the long-term outcome of epilepsy surgery and the cognitive outcomes of superselective surgical procedures.

RECENT FINDINGS

Current studies indicate that neuropsychological impairments are prevalent already at the onset of epilepsy and even before, social cognition (i.e., emotion recognition and theory of mind) is impaired in different epilepsy populations, the long-term outcome of epilepsy surgery is mostly characterized by a stable or even improved cognitive status, and superselective epilepsy surgeries are associated with a promising neuropsychological outcome.

SUMMARY

The high prevalence of cognitive deficits around epilepsy onset challenges the assumption that epilepsy is the major cause of cognitive problems and calls for early neuropsychological diagnostics. Social cognition seems to be a relevant domain that is not yet routinely considered in epilepsy. The cognitive long-term outcome of epilepsy surgery is mostly positive. Stereotactic thermocoagulation and gamma knife surgery appear to be cognitively safe procedures.

Facial emotion perception in patients with epilepsy: A systematic review with meta-analysis

Facial emotion perception is a fundamental social competency relying on a specialised, yet distributed, neural network. This review aimed to determine whether patients with epilepsy have facial emotion perception accuracy impairments overall, or for a subset of emotions (anger, disgust, happiness, sadness, fear, and surprise), and the relationship to epilepsy type, demographic/treatment variables, and brain organisation. Database searches used PRISMA guidelines with strict inclusion/exclusion criteria. Thirty included studies assessed patients with temporal lobe (TLE; n=709), frontocentral (FCE; n=22), and genetic generalised (GGE; n=48) epilepsy. Large deficits emerged in patients with epilepsy compared to controls (n=746; Hedges' g=0.908-1.076). Patients with TLE were significantly impaired on all emotions except surprise; patients with GGE were significantly impaired in anger, disgust, and fear perception. Meta-regression of patients with TLE revealed younger age at testing was associated with lower accuracy. This review provides evidence for marked global deficits of emotion perception in epilepsy, with differential emotion-specific impairment patterns in patients with TLE and GGE.

The right hemisphere's contribution to discourse processing: A study in temporal lobe epilepsy

OBJECTIVE

Discourse skills - in which the right hemisphere has an important role - enables verbal communication by selecting contextually relevant information and integrating it coherently to infer the correct meaning. However, language research in epilepsy has focused on single word analysis related mainly to left hemisphere processing. The purpose of this study was to investigate discourse abilities in patients with right lateralized medial temporal lobe epilepsy (RTLE) by comparing their performance to that of patients with left temporal lobe epilepsy (LTLE).

METHODS

74 pharmacoresistant temporal lobe epilepsy (TLE) patients were evaluated: 34 with RTLE and 40 with LTLE. Subjects underwent a battery of tests that measure comprehension and production of conversational and narrative discourse. Disease related variables and general neuropsychological data were evaluated.

RESULTS

The RTLE group presented deficits in interictal conversational and narrative discourse, with a disintegrated speech, lack of categorization and misinterpretation of social meaning. LTLE group, on the other hand, showed a tendency to lower performance in logical-temporal sequencing.

SIGNIFICANCE

RTLE patients showed discourse deficits which have been described in right hemisphere damaged patients due to other etiologies. Medial and anterior temporal lobe structures appear to link semantic, world knowledge, and social cognition associated areas to construct a contextually related coherent meaning.

Labelling Facial Affect in Context in Adults with and without TBI

Recognition of facial affect has been studied extensively in adults with and without traumatic brain injury (TBI), mostly by asking examinees to match basic emotion words to isolated faces. This method may not capture affect labelling in everyday life when faces are in context and choices are open-ended. To examine effects of context and response format, we asked 148 undergraduate students to label emotions shown on faces either in isolation or in natural visual scenes. Responses were categorised as representing basic emotions, social emotions, cognitive state terms, or appraisals. We used students' responses to create a scoring system that was applied prospectively to five men with TBI. In both groups, over 50% of responses were neither basic emotion words nor synonyms, and there was no significant difference in response types between faces alone vs. in scenes. Adults with TBI used labels not seen in students' responses, talked more overall, and often gave multiple labels for one photo. Results suggest benefits of moving beyond forced-choice tests of faces in isolation to fully characterise affect recognition in adults with and without TBI.

Why epilepsy challenges social life

Social bonds are at the center of our daily living and are an essential determinant of our quality of life. In people with epilepsy, numerous factors can impede cognitive and affective functions necessary for smooth social interactions. Psychological and psychiatric complications are common in epilepsy and may hinder the processing of social information. In addition, neuropsychological deficits such as slowed processing speed, memory loss or attentional difficulties may interfere with enjoyable reciprocity of social interactions. We consider societal, psychological, and neuropsychological aspects of social life with particular emphasis on socio-cognitive functions in temporal lobe epilepsy. Deficits in emotion recognition and theory of mind, two main aspects of social cognition, are frequently observed in individuals with mesial temporal lobe epilepsy. Results from behavioural studies targeting these functions will be presented with a focus on their relevance for patients' daily life. Furthermore, we will broach the issue of pitfalls in current diagnostic tools and potential directions for future research. By giving a broad overview of individual and interpersonal determinants of social functioning in epilepsy, we hope to provide a basis for future research to establish social cognition as a key component in the comprehensive assessment and care of those with epilepsy.

Are "Theory of Mind" Skills in People with Epilepsy Related to How Stigmatised They Feel? An Exploratory Study

Feelings of stigma are one of the main burdens reported by people with epilepsy (PWE). Adults with temporal or frontal lobe epilepsy and children with idiopathic generalised epilepsy are at risk of Theory of Mind (ToM) deficits. ToM refers to social cognitive skills, including the ability to understand the thoughts, intentions, beliefs, and emotions of others. It has been proffered that ToM deficits may contribute to the feelings of stigma experienced by PWE. In this study we tested this for the first time. We also determined the association between clinical and demographic factors and ToM performance. Five hundred and three PWE were recruited via epilepsy organisations and completed measures online. Feelings of stigma were measured using Jacoby's Stigma Scale, whilst the Reading the Mind in the Eyes Test and the Faux Pas Test measured ToM. The median age of participants was 37 years, their median years living with epilepsy were 15, and 70% had experienced seizures in the prior 12 months. Feelings of stigma held a negligible, negative, and nonsignificant association with ToM performance (r s   -0.02 and -0.05). Our results indicate that the ToM model for understanding epilepsy stigma has limited utility and alternative approaches to understanding and addressing epilepsy-related stigma are required.

Social cognition in temporal lobe epilepsy: A systematic review and meta-analysis

OBJECTIVE

There is increasing evidence suggesting that social cognitive abilities are impaired in temporal lobe epilepsy (TLE), the most common form of focal epilepsies.

METHODS

In this meta-analysis, 31 studies investigating theory of mind (ToM) and facial emotion recognition performances of 1356 patients with TLE (351 postsurgery) and 859 healthy controls were included.

RESULTS

Patients with TLE had significant deficits in ToM (d = 0.73–0.89) and recognition of facial emotions. There were no significant differences in severity of social cognitive deficits between patients with TLE with or without medial temporal lobectomy. Earlier onset of seizures was associated with ToM impairment. Right-sided TLE was associated with more severe deficits in recognition of fear, sadness, and disgust.

CONCLUSIONS

Social cognitive information processing is impaired in TLE, and the potential role of these deficits in functional impairment needs to be further investigated.

Impaired social cognition in patients with interictal epileptiform discharges in the frontal lobe

BACKGROUND

Patients with epilepsy frequently experience cognitive impairments, including impairments in social cognition. However, there is a lack of direct examinations of the affective and cognitive aspects of social cognition in such patients. The neural correlates remain to be identified. The present study was designed to examine the degree of impairments in different aspects of social cognition including empathy, emotion recognition, and Theory of Mind (ToM) in patients with epilepsy. In addition, we further explored factors related to the impairments, highlighting the specific importance of the frontal region.

MATERIALS AND METHODS

After 24-hour EEG monitoring, 53 patients with epilepsy were administered a neuropsychological battery of tests for basic intelligence assessment and then were tested with the Interpersonal Reactive Index, the "Yoni" task, the Emotion Recognition Test, the Reading the Mind in the Eyes test, and other neuropsychological tests. The clinical variables potentially affecting the ability to accomplish these tests were taken into account. We divided the patients into those having frontal lobe interictal epileptiform discharges (group with frontal IEDs) and those with seizures originating outside the frontal or temporal lobes (group with extrafrontal IEDs). Sixty healthy individuals served as controls.

RESULTS

The group with frontal IEDs achieved the most severe deficits in emotion recognition, ToM, and cognitive empathy, while affective empathy was intact. Moreover, the performance scores of empathy in the group with frontal IEDs were selectively correlated with their executive function scores, which are believed to be associated with orbitofrontal functioning. In contrast, patients with epilepsies not originating from the frontal or temporal lobes may also be at risk of impairments in social cognition, albeit to a lesser extent.

CONCLUSIONS

The preliminary findings suggest that patients with epilepsy, especially those having frontal lobe interictal epileptiform discharges, have associated general social cognition deficits. At the clinical level, these results are in line with previous findings regarding social cognition and the importance of the prefrontal area in the integration of cognition and affect. At the theoretical level, our findings also provide evidence for the functional independence of cognitive from affective aspects of empathy.