On the psychopathology of unilateral temporal lobe epilepsy

Consensus-based recommendations for the diagnosis and treatment of anxiety and depression in children and adolescents with epilepsy: A report from the Psychiatric Pediatric Issues Task Force of the International League Against Epilepsy

The Psychiatric Pediatric Issues Task Force of the International League Against Epilepsy (ILAE) aimed to develop recommendations for the diagnosis and treatment of anxiety and depression in children and adolescents with epilepsy. The Task Force conducted a systematic review and identified two studies that assessed the accuracy of four screening measures for depression and anxiety symptoms compared with a psychiatric interview. Nine studies met the eligibility criteria for treatment of anxiety and depressive disorders or symptoms. The risk of bias and certainty of evidence were assessed. The evidence generated by this review followed by consensus where evidence was missing generated 47 recommendations. Those with a high level of agreement (≥80%) are summarized. Diagnosis: (1) Universal screening for anxiety and depression is recommended. Closer surveillance is recommended for children after 12 years, at higher risk (e.g., suicide-related behavior), with subthreshold symptoms, and experiencing seizure worsening or therapeutic modifications. (2) Multiple sources of ascertainment and a formal screening are recommended. Clinical interviews are recommended whenever possible. The healthcare provider must always explain that symptom recognition is essential to optimize treatment outcomes and reduce morbidity. (3) Questioning about the relationship between symptoms of anxiety or depression with seizure worsening/control and behavioral adverse effects of antiseizure medications is recommended. Treatment: (1) An individualized treatment plan is recommended. (2) For mild depression, active monitoring must be considered. (3) Referral to a mental health care provider must be considered for moderate to severe depression and anxiety. (4) Clinical care pathways must be developed. (5) Psychosocial interventions must be tailored and age-appropriate. (6) Healthcare providers must monitor children with epilepsy who are prescribed antidepressants, considering symptoms and functioning that may not improve simultaneously. (7) Caregiver education is essential to ensure treatment adherence. (8) A shared-care model involving all healthcare providers is recommended for children and adolescents with epilepsy and mental health disorders. We identified clinical decisions in the management of depression and anxiety that lack solid evidence and provide consensus-based guidance to address the care of children and adolescents with epilepsy.

Revisiting personality in epilepsy: Differentiation of personality in two epilepsies starting in adolescence

PURPOSE

The purpose of this study was to investigate personality characteristics and clinical parameters in two well-defined epilepsies: mesial temporal lobe epilepsy related to hippocampal sclerosis (MTLE/HS) and juvenile myoclonic epilepsy (JME) through NEO Revised Personality Inventory (NEO-PI-R) and Neurobehavior Inventory (NBI) standardized instruments.

METHODS

One hundred patients undergoing corticoamygdalohippocampectomy (CAH), 100 patients with JME, and 100 control subjects answered the personality measures. Clinical parameters such as psychiatric symptoms, seizure frequency, duration of epilepsy, and side of the lesion in MTLE/HS group were investigated. Statistical analysis consisted of the mean and standard deviation (SD) of each variable. Student's t-test or Fisher exact test were used according to the variable studied.

RESULTS

The three groups were within the average range of NEO-PI-R and NBI, although 'tendencies' and differences were demonstrated. The MTLE/HS and control subjects had a similar profile: low scores in Neuroticism and high in Conscientiousness (r = -0.330; p < 0.001/r = -0.567; p < 0.001, respectively) in opposition to what occurred in JME, low in Conscientiousness and high in Neuroticism (r = -0.509; p = 0.005). The NBI 'sense of personal destiny' trait was higher (3.15; p = 0.003) in MTLE/HS than in JME and controls. The JME 'law and order' scores were lower than in other groups (p = 0.024). A tendency towards specific NBI traits differentiates MTLE/HS (Factor 3) from JME (Factor 1) groups. Psychiatric symptoms and seizure frequency were correlated with worse scores in NBI and, especially, in Neuroticism domain of NEO-PI-R.

CONCLUSION

Specific personality features were linked to each epileptic disease. These findings highlight the importance of considering unique features linked to epilepsy conditions in daily clinical observation to develop support programmes.

The neural basis of optimism and pessimism

Our survival and wellness require a balance between optimism and pessimism. Undue pessimism makes life miserable; however, excessive optimism can lead to dangerously risky behaviors. A review and synthesis of the literature on the neurophysiology subserving these two worldviews suggests that optimism and pessimism are differentially associated with the two cerebral hemispheres. High self-esteem, a cheerful attitude that tends to look at the positive aspects of a given situation, as well as an optimistic belief in a bright future are associated with physiological activity in the left-hemisphere (LH). In contrast, a gloomy viewpoint, an inclination to focus on the negative part and exaggerate its significance, low self-esteem as well as a pessimistic view on what the future holds are interlinked with neurophysiological processes in the right-hemisphere (RH). This hemispheric asymmetry in mediating optimistic and pessimistic outlooks is rooted in several biological and functional differences between the two hemispheres. The RH mediation of a watchful and inhibitive mode weaves a sense of insecurity that generates and supports pessimistic thought patterns. Conversely, the LH mediation of an active mode and the positive feedback it receives through its motor dexterity breed a sense of confidence in one's ability to manage life's challenges, and optimism about the future.

Neurobehavior inventory: correlation with clinical aspects and quality of life in patients with epilepsy

Fifty-five adult patients with epilepsy were evaluated, and the Neurobehavior Inventory (NBI) was administered. The relationship between the NBI data and clinical aspects and quality of life (QoL) was studied. The total NBI score was 58 ± 18.2. The domains with the highest scores were "religious conviction", "orderliness", and "sense of personal destiny". There was a significant difference in "hatred and revenge" and "religious conviction" according to the epileptic syndrome. The "physical well-being" score was higher for patients with mesial temporal lobe epilepsy with right hippocampal sclerosis than for left sclerosis (2.77 ± 1.6 × 1.57 ± 0.5, respectively, p = 0.002). The total NBI score was higher in patients with psychiatric comorbidities and with depression according to the Hamilton Depression Scale and was negatively correlated with the "emotional well-being" QOLIE score (-0.398, p = 0.005). The NBI findings showed that behavioral changes can be present in various epilepsies and that there is a complex bidirectional neurobiological relationship between epilepsy and psychiatric comorbidity, sustained by common physiopathological mechanisms.

Psychosocial adjustment of epilepsy patients in Cyprus

This study investigated aspects of psychosocial adjustment in epilepsy patients in Cyprus. Sixty-three patients under 55 years of age with idiopathic or symptomatic epilepsy and 89 neurologically matched healthy volunteers participated. Subjects completed the State and Trait Anxiety Inventory and the Beck Depression Inventory; patients with epilepsy also completed the Epilepsy Foundation Concerns Index. Results showed that patients with symptomatic epilepsy had significantly higher scores on state and trait anxiety and depressive symptoms. Sociodemographic characteristics including gender, marital status, and education levels contributed to differences in trait and state anxiety, depressive symptom scales, autonomy concerns, and fear for seizure recurrence. Variables such as poor seizure control and use of polytherapy were associated with lower adjustment scores and reduced psychosocial outcome. Finally, patients with epilepsy scored significantly higher on depression and anxiety symptoms. The results provide further evidence on challenges patients with epilepsy face and on the need for implementing psychosocial prevention programs.

A longitudinal study of psychological features in patients before and two years after epilepsy surgery

This study aimed at investigating psychological features before and two years after epilepsy surgery. Fifty patients, 39 with temporal lobe epilepsy (TLE) and 11 with frontal lobe epilepsy (FLE), were assessed at baseline and two years postoperatively with the Karolinska Scales of Personality (KSP). Baseline group level outcome was normal while individual level analyses delineated some mild to moderate degrees of psychological problems exceeding the normal range in subsets of patients. Features of hostility characterized half of the FLE and one-fourth of the TLE patients. Above 1/3 in each group had dependency features. About 1/3 of the TLE patients suffered from psychasthenia. In conclusion, even though group levels were normal, several patients had psychological problems. The main longitudinal result was that the personality features were stable and did not change after epilepsy surgery.

[Emotional and affective disorders, anxiety and personality disorders in epilepsies]

The wide spectrum of comorbid mental disorders in epilepsy includes anxiety, affective as well as personality disorders and psychosis. While the prevalence of mental disorders in the general epilepsy population is reported to be 6%, for focal epilepsies, especially temporal lobe epilepsy, this rate is considerably higher and the numbers given in the literature range from 20 to 70%, of which anxiety and depression have the highest share.According to the diathesis-stress model pre-existing vulnerability factors, neurobiological factors, iatrogenic effects and psychosocial stress factors are individually of different significance in the development of mental disorders in epilepsy. Learned reactions in answer to psychosocial stress as well as structural and functional disturbances in the neuronal limbic networks for the regulation of affective, emotional and social behaviour are fundamental driving factors. Furthermore, therapeutic measures may add to the development of mental health problems. Several antiepileptic drugs (AE) have proven their value in the psychiatric treatment of mental disorders; however, AE may also cause psychiatric side effects.Similarly, although established as a successful treatment option in focal epilepsies, surgery is also reported to have an influence on mental health. Newly diagnosed mental problems are rarely reported after surgery; more often positive changes are observed across the entire spectrum of mental disorders associated with epilepsy.

Psychosocial impairments in children with epilepsy depend on the side of the focus

This article explores the idea that epileptic activity may interfere with psychosocial functions and development in children. In an adult population with epilepsy, left hemispheric seizure focus predicts worse psychosocial functioning. The developmental aspects of these disturbances require further studies. We studied self-report measures of cognitive (locus of control) and emotional (Beck Youth Inventories of Emotional and Social Impairment) functions in 30 children with partial epilepsy (6-15 years) and 60 healthy matched controls. Multivariate statistics revealed significant lateralization effects, with left-sided foci (n=15) leading to more external locus of control. Opposite to adults, the children with right hemispheric foci (n=15) exhibited more emotional impairments (anger, disruptive behavior) than the left hemispheric group. The cognitive and emotional dysfunctions in epilepsy may result from the interaction of focus lateralization and brain development. The cognitive disturbances beginning in childhood may lead to the stronger emotional impairments observed in adults with left hemispheric seizures.

Comparison of personality traits in patients with frontal and temporal lobe epilepsies

The current study sought to characterize and compare personality traits of patients with temporal lobe epilepsy (TLE) and frontal lobe epilepsy (FLE). Ninety-seven adults with medically intractable epilepsy (TLE n=58, FLE n=39) completed the Personality Assessment Inventory (PAI) as part of routine preoperative investigations. Not surprisingly, both epilepsy groups endorsed significantly more symptoms across PAI clinical scales than the normative sample, most notably on scales assessing Depression and Somatic Complaints. Direct comparison of personality profiles of people with FLE and TLE revealed that FLE was associated with relative elevations on scales assessing emotional lability and relationship difficulties (i.e., Mania, Borderline Features, Antisocial, Stress, and Nonsupport). Although effect sizes were moderate to large, the clinical significance of these differences was questionable (<1 SD). However, results of a logistic regression suggested that the Borderline Features and Anxiety scales have incremental validity in predicting seizure site (FLE vs TLE) above education and duration of recurrent seizures. These results suggest that patients with FLE may exhibit more behavioral traits associated with frontal dysfunction than patients with TLE.

Impaired facial emotion recognition in patients with mesial temporal lobe epilepsy associated with hippocampal sclerosis (MTLE-HS): Side and age at onset matters

To define the determinants of impaired facial emotion recognition (FER) in patients with mesial temporal lobe epilepsy associated with hippocampal sclerosis (MTLE-HS), we examined 76 patients with unilateral MTLE-HS, 36 prior to antero-mesial temporal lobectomy (AMTL) and 40 after AMTL, and 28 healthy control subjects with a FER test consisting of 60 items (20 each for anger, fear, and happiness). Mean percentages of the accurate responses were calculated for different subgroups: right vs. left MTLE-HS, early (age at onset <6 years) vs. late-onset, and before vs. after AMTL. After controlling for years of education, duration of epilepsy and number of antiepileptic drugs (AEDs) taken, on multivariate analysis, fear recognition was profoundly impaired in early-onset right MTLE-HS patients compared to other MTLE patients and control subjects. Happiness recognition was significantly better in post-AMTL MTLE-HS patients compared to pre-AMTL patients while anger and fear recognition did not differ. We conclude that patients with right MTLE-HS with age at seizure onset <6 years are maximally predisposed to impaired fear recognition. In them, right AMTL does not further worsen FER abilities. Longitudinal studies comparing FER in the same patients before and after AMTL will be required to refine and confirm our cross-sectional observations.

Interictal Depression, Anxiety, Personality Traits, and Psychological Dissociation in Patients with Temporal Lobe Epilepsy (TLE) and Extra-TLE

PURPOSE

This study was performed to investigate the relation between symptoms of interictal depression, anxiety, personality traits, and psychological dissociation with the localization and lateralization of the epileptogenic zone in patients with partial epilepsy.

METHODS

All patients were diagnosed according to the localization-related concept of the 1989 International League Against Epilepsy (ILAE) Classification of Epilepsies and Epileptic Syndromes, and the localization and lateralization of the epileptogenic zone was established by using the clinical criteria for noninvasive presurgical evaluation. This resulted in 67 patients with temporal lobe epilepsy (TLE) and 64 patients with extra-TLE. All patients were assessed on the various aspects of psychopathology by using a comprehensive battery of standardized diagnostic instruments.

RESULTS

We did not find the hypothesized excess of psychiatric symptoms in patients with (mesial) TLE in comparison with patients with extra-TLE. We also found no differences between patients with the lateralization of epilepsy in the left versus the right hemisphere.

CONCLUSIONS

TLE per se cannot be considered a risk factor in developing more or more severe symptoms of psychopathology in patients with partial epilepsy. Concomitant factors, such as the duration of epilepsy, seizure frequency, and frontal lobe dysfunction may play an additional role. Our findings support the hypothesis of a multifactorial explanation for the psychiatric symptoms in patients with epilepsy.