Characterizing psychosocial outcome trajectories following seizure surgery

"Do I still have epilepsy?" Epilepsy identity 15-20 years after anterior temporal lobectomy

OBJECTIVE

Identity is a multifaceted construct, comprising personal identity (sense of being a unique individual) and social identity (the sense-of-self derived from membership of social groups). Social identity involves explicit identification with a group ("I am …") and implicit behaviors or attitudes associated with group membership. Following successful treatment with surgery, patients with epilepsy can undergo a complex and lasting change in personal identity. To date, there has been no research into postoperative social epilepsy identity (SEI). We sought to examine SEI 15-20 years post-surgery, and the relationship between SEI and satisfaction with surgery, psychosocial improvements, mood, and health-related quality of life (HRQoL).

METHODS

Thirty-two patients who underwent anterior temporal lobectomy (ATL; 19 female) were recruited, with a median follow-up of 18 years (interquartile range [IQR] = 2.5). Using a novel interactive online program, we collected data on SEI, satisfaction with surgery, and perceived psychosocial improvements, alongside standardized measures of mood (Neurological Disorders Depressio Inventory-Epilepsy; Patient Health Questionnaire-Generalised Anxiety Disorder-7 item) and HRQoL (Quality of Life in Epilepsy-31 item). Non-parametric analyses were used to analyse the data.

RESULTS

Twenty-five percent of patients were free of disabling seizures since surgery, yet 65% stated they no longer had epilepsy and >90% reported satisfaction with surgery. Explicitly discarding SEI was positively associated with HRQoL at long-term follow-up, over and above seizure outcome. Implicit SEI was expressed as (a) acceptance of epilepsy, (b) a sense of belonging to the epilepsy community, and (c) difficulty disclosing and discussing epilepsy. Difficulty disclosing and discussing epilepsy was associated with increased anxiety and lower HRQoL.

SIGNIFICANCE

At long-term follow-up, over half of our patients reported an explicit change in SEI, which could promote better HRQoL. In contrast, difficulty with disclosure of epilepsy was associated with increased anxiety and reduced HRQoL, possibly reflecting the ongoing effects of stigma. These findings highlight the importance of understanding changes in patient social identity for promoting long-term well-being after surgery.

Social functioning and health-related quality of life trajectories in people with epilepsy after epilepsy surgery

OBJECTIVE

An improvement in quality of life (QoL) over time after epilepsy surgery has been demonstrated in people with epilepsy; however, social functioning has been less investigated. We conducted this study to examine whether postsurgical improvement is parallel between QoL and social functioning in patients with epilepsy.

METHODS

We retrospectively reviewed patients who underwent epilepsy surgery. All participants completed a comprehensive neuropsychological assessment, the Quality of Life in Epilepsy Inventory (QOLIE-89) questionnaire, and the Social and Occupational Functioning Scale for Epilepsy (SOFSE) before surgery and at 3 months, 6 months, and 1 year after surgery. Demographic and epilepsy-related information was also collected. Generalized estimating equations with identity links were used to model the QOLIE-89 and SOFSE over time and possible associated factors. A p < 0.05 was considered statistically significant.

RESULTS

A total of 76 patients, including 36 males and 43 females aged 18 to 62 years were collected. Both total QOLIE-89 and overall SOFSE improved over time after epilepsy surgery (adjusted p value < 0.001 and 0.002, respectively, with Bonferroni's correction). Total QOLIE-89 improved 3 months after surgery, while overall SOFSE showed no significant improvement until 6 months after surgery. The presurgical Full-Scale Intelligence Quotient (FSIQ) of the Wechsler Adult Intelligence Scale-III and years of education were significantly associated with time-dependent improvement for both total QOLIE-89 and overall SOFSE (p value < 0.001). At one year after surgery, overall SOFSE and total QOLIE-89 scores were significantly higher in the seizure-free group than in the nonseizure-free group (p value = 0.040 and 0.032, respectively).

CONCLUSION

Social functioning significantly improved in people with epilepsy after surgery as QoL, but it took more time to exhibit improvement. People with better FSIQ and more years of education had better improvement in social functioning over time. The early intervention of rehabilitation programs after epilepsy surgery might be necessary to facilitate the improvement in social functioning.

A patient-centered approach to understanding long-term psychosocial adjustment and meaning-making, 15 to 20 years after epilepsy surgery

OBJECTIVE

Different psychosocial trajectories have been identified following treatment with epilepsy surgery, as patients adjust to possible changes in seizure frequency and the subsequent impact on their psychosocial functioning. Qualitative research has been key to understanding this adjustment process, particularly in the short-term (2-5 years). Currently, however, there is a lack of qualitative research examining longer-term (>15 years) outcomes, precluding the same rich, detailed understanding of longer-term psychosocial outcomes. Using a grounded theory approach, we explored how patients reflected on and made sense of their adjustment trajectories, 15 to 20 years after surgery. This included the impact of surgery on their sense of self and broader psychosocial functioning.

METHODS

We recruited 40 adult patients who had undergone anterior temporal lobectomy (ATL) 15 to 20 years ago (24 females; 26 left-sided). Median age at habitual seizure onset was 9.7 years (Interquartile range; IQR = 13.8), and at surgery was 31 years (IQR = 12). Median length of follow-up was 18.4 years (IQR = 4.3). Comprehensive one-on-one interviews (median time = 86 min, IQR = 28) were used to elicit patient experiences of their surgery and subsequent psychosocial outcomes. Data were analyzed using a grounded theory inductive-deductive process.

RESULTS

Patient narratives revealed a common process of psychosocial change and meaning-making triggered by surgery, which was often perceived as a major turning point in life. Patients reflected on moving through an early postsurgical period (<5 years) of upheaval and psychological disequilibrium. While this period was often remembered as stressful, difficulties were softened and/or reframed in hindsight. Through this process of reframing and meaning-making, patients were able to reestablish equilibrium and a sense of normality. Differences were evident in how patients navigated the process of meaning-making, and the extent to which they felt surgery had changed their self-identity.

DISCUSSION

We propose a model of postsurgical meaning-making, evident in the narratives of patients who have undergone ATL, providing a new perspective on long-term psychosocial outcomes. This model contributes to our understanding of patient well-being and quality of life, by acknowledging the active role that patients play in seeking to create their own sense of normality after epilepsy surgery.

Psychiatric complications after epilepsy surgery… but where are the psychiatrists?

In patients with refractory epilepsy, there is a significant risk of postoperative psychiatric complications after epilepsy surgery. The main risk factors for this phenomenon include a lifetime or family history of psychiatric illness; these risk factors can be easily identified through a preoperative evaluation performed by a psychiatrist. Despite this, very few comprehensive epilepsy centers include a psychiatrist on the treatment team. Preoperative evaluations often fail to identify patients at risk of postoperative psychiatric complications, thus missing the opportunity to counsel and prophylactically treat patients at risk. In this article, we review the risk factors for the development of postoperative psychiatric complications and discuss the reasons why epilepsy centers continue to perform presurgical evaluations without psychiatrists. Additionally, we provide practical solutions for neurologists in the identification and management of postoperative psychiatric disorders. This article is part of the Special Issue "Obstacles of Treatment of Psychiatric Comorbidities in Epilepsy".

Identifying the trajectory of social milestones 15-20 years after epilepsy surgery: Realistic timelines for postsurgical expectations

OBJECTIVE

Patients often undertake epilepsy surgery with the expectation that it will lead to improvements in their social situation. Short- to medium-term research consistently points toward improvements in social outcomes; however, no study has mapped out postsurgical social timelines, particularly for longer-term (>15 years) outcomes.

METHODS

We recruited 39 patients who had undergone anterior temporal lobectomy (ATL) for drug-resistant temporal lobe epilepsy (TLE) between 1994 and 2002. The cohort (24 females) had a median age of 49 years (range 38-67), age of habitual seizure onset was 9.5 years (range 0.5-29 years), and age at surgery was 31 years (range 20-53). Patients were followed up for a median of 18.4 years postsurgery (IQR = 4.4). Using data obtained from semistructured interviews, we conducted a comprehensive qualitative analysis of patients' self-reported postsurgical social trajectories. Self-report questionnaires were used to assess mood and health-related quality of life (HRQOL) at the time of interview.

RESULTS

There was a common sequence of social milestone achievement, spanning 20 years postsurgery. Typically, patients first (re)gained their license, then attempted educational and vocational gains, followed by establishing long-term relationships and finally a family unit. Rare, intermittent seizures postsurgery did not appear to have detrimental effects on social trajectories. Those who experienced a reduction in seizures showed increased likelihood of attaining social milestones compared to those with ongoing seizures.

SIGNIFICANCE

Achieving social milestones after epilepsy surgery may take considerably longer than patients are expecting prior to surgery. The pattern of social milestone outcome resembled a process of psychosocial development. These findings have important implications for presurgical counseling and postsurgical rehabilitation.

Determinants of health and wellbeing in refractory epilepsy and surgery: The Patient Reported, ImpleMentation sciEnce (PRIME) model

This paper offers a new way of understanding the course of a chronic, neurological condition through a comprehensive model of patient-reported determinants of health and wellbeing: The Patient Reported ImpleMentation sciEnce (PRIME) model is the first model of its kind to be based on patient-driven insights for the design and implementation of initiatives that could improve tertiary, primary, and community healthcare services for patients with refractory epilepsy, and has broad implications for other disorders; PRIME focuses on: patient-reported determinants of health and wellbeing, pathways through care, gaps in treatment and other system delays, patient need and expectation, and barriers and facilitators to high-quality care provision; PRIME highlights that in the context of refractory epilepsy, patients value appropriate, clear, and speedy referrals from primary care practitioners and community neurologists to specialist healthcare professionals based in tertiary epilepsy centers. Many patients also want to share in decisions around treatment and care, and gain a greater understanding of their debilitating disease, so as to find ways to self-manage their illness more effectively and plan for the future. Here, PRIME is presented using refractory epilepsy as the exemplar case, while the model remains flexible, suitable for adaptation to other settings, patient populations, and conditions; PRIME comprises six critical levels: 1) The Individual Patient Model; 2) The Patient Relationships Model; 3) The Patient Care Pathways Model; 4) The Patient Transitions Model; 5) The Pre- and Postintervention Model; and 6) The Comprehensive Patient Model. Each level is dealt with in detail, while Levels 5 and 6 are presented in terms of where the gaps lie in our current knowledge, in particular in relation to patients' journeys through healthcare, system intersections, and individuals adaptive behavior following resective surgery, as well as others' views of the disease, such as family members.

Predictive coding: A contemporary view on the burden of normality and forced normalization in individuals undergoing epilepsy surgery

Following epilepsy surgery, a good psychosocial outcome is not necessarily contingent on a good seizure outcome. Increasingly, it is believed that "successful" surgery is a combination of both an acceptable and expected seizure status as well as the individual's perception of improvements in quality of life (QOL). The factors that create this optimal outcome remain an ongoing area of research in the epilepsy community. That being said, there have been some major breakthroughs in observing and understanding poor outcomes seen in a subset of postoperative patients with epilepsy. Characteristics of burden of normality and forced normalization are two phenomena that have been evident in cases of poor postoperative outcomes. In this review, we provide a summary of research and concepts used to explain these poor QOL outcomes for a seemingly successful surgery and suggest a contemporary view in understanding the mechanism of forced normalization through understanding the brain as a predictive organ. Using such a predictive coding model together with recommendations of other studies, we suggest the crucial need for a preoperative intervention addressing patient predictions and expectations to optimize on the benefits achievable through epilepsy surgery.

Stable psychological functioning after surgery for epilepsy: An informant-based perspective

OBJECTIVE

Psychological adjustment following surgery for epilepsy has been assessed primarily with self-report measures. In the current work, we investigated pre- to postoperative changes in various dimensions of personality and behavior from the perspective of a well-known family member or friend for 27 patients operated on for medically intractable epilepsy.

METHODS

For each patient, a close family member or friend ("informant") provided pre- and postoperative ratings on five dimensions of personality and behavior. All ratings were collected during the chronic epoch of recovery, when personality and behavior of the patients are relatively stable. Self-report measures were also used to examine the relation between self-report and informant-report assessment of psychological adjustment. Lastly, the relation between seizure outcomes and psychological adjustment was investigated.

RESULTS

Personality and behavior characteristics, as rated by an informant, remained stable and within a normal range of functioning following surgery for epilepsy. There were no significant differences between pre- and postoperative levels of executive functioning, social behavior, hypo-emotionality, irascibility, or distress. Informant-ratings on levels of current depression and overall current psychological functioning were significantly related to patient reports of current depression and global personality characteristics derived from the MMPI-2 (e.g., psychasthenia, schizophrenia, hypomania, psychopathic deviation, social introversion). There was no significant relationship between seizure outcome and psychological adjustment.

SIGNIFICANCE

Informant-based reports on psychological adjustment following surgery for epilepsy provide a unique perspective on important aspects of the success of the intervention. Assessing outcomes beyond seizure status is important for developing a comprehensive understanding of the potential consequences of surgery for epilepsy. Based on the current work, personality and behavior seem to be stable following surgery for epilepsy, and our study provides a unique informant-based perspective on this encouraging result.

Preoperative and early postoperative quality of life after major surgery - a prospective observational study

BACKGROUND

Changes in health-related quality of life (HRQoL) several days after surgery have rarely been investigated. We aimed to estimate the perioperative change of HRQoL, to identify patients with clinically relevant decrease in postoperative HRQoL and to establish factors associated with this decrease in HRQoL at day 30 after major surgery.

METHODS

Patients scheduled for major surgery at a university hospital were enrolled. Based on the HRQoL SF-12 questionnaire, the preoperative physical component summary (PCS) score, preoperative mental component summary (MCS) score, and postoperative PCS and MCS scores at day 30 were recorded. Minimal clinically important difference (MCID) was defined as those with a decrease of at least one half of the standard deviation (SD) of preoperative PCS or MCS scores. Differences between the groups with or without decreased HRQoL were investigated using univariate comparisons. A multiple logistic regression model was performed to evaluate the predictive value of potential perioperative variables.

RESULTS

The mean ± SD preoperative PCS score was 38.5 ± 10.6, postoperative score was 35.1 ± 7.8 (p = .004) in 85 patients. Thirty-five patients (41.2%) had a clinically relevant decrease of the postoperative PCS score. A normal to high preoperative exercise metabolic capacity measured with metabolic equivalent of task (MET) (p = .01) was a predictor of the decrease in postoperative PCS. The mean preoperative MCS scores (p = .395) were 42.2 (SD 12.8) preoperative, and 43.45 (SD 12.4) postoperative, respectively.

CONCLUSIONS

Major surgery decreases postoperative PCS scores of HRQoL at 30 days. A normal to high exercise capacity was a predictor of a clinically relevant decrease of postoperative PCS scores.

TRIAL REGISTRATION

07-107 (Ethical Committee NAC of Geneva University Hospitals).

Life outcomes of anterior temporal lobectomy: serial long-term follow-up evaluations

BACKGROUND

At 3 time points, this study examined long-term psychosocial life outcomes of individuals who underwent anterior temporal lobectomy in comparison with individuals with temporal lobe epilepsy who were medically managed.

OBJECTIVE

To examine seizure frequency, employment, driving, independent living, financial independence, mental health, and quality of life at each follow-up assessment, as well as predictors of outcomes.

METHODS

All participants were diagnosed with medically intractable complex partial seizures of temporal lobe origin with or without secondary generalization. A structured clinical interview was used at all 3 time points. Information was obtained regarding seizure frequency, antiepilepsy medications, employment, driving status, financial assistance, and independent living. Additionally, questions regarding quality of life, satisfaction with surgery, and the presence of depression or anxiety were included. Participants were, on average, 17 years postsurgery.

RESULTS

Surgery resulted in significantly improved and sustained seizure outcomes. At the first, second, and third follow-ups, 67%, 72%, and 67% of participants in the surgery group remained seizure-free in the year before the follow-up interview. At each follow-up, 97%, 84%, and 84% reported that they would undergo surgery again. Seizure freedom predicted driving outcomes at all 3 time points, but was not a significant predictor for employment, independent living, or financial independence. Psychosocial life outcomes in the surgical group were improved and maintained over time in comparison with the medically managed group.

CONCLUSION

This systematic long-term investigation provides strong support for the positive impact of anterior temporal lobectomy on psychosocial life outcomes including driving, employment, independent living, and financial independence.

Narratives reflecting the lived experiences of people with brain disorders: common psychosocial difficulties and determinants

BACKGROUND

People with brain disorders - defined as both, mental disorders and neurological disorders experience a wide range of psychosocial difficulties (PSDs) (e.g., concentrating, maintaining energy levels, and maintaining relationships). Research evidence is required to show that these PSDs are common across brain disorders.

OBJECTIVES

To explore and gain deeper understanding of the experiences of people with seven brain disorders (alcohol dependency, depression, epilepsy, multiple sclerosis, Parkinson's disease, schizophrenia, stroke). It examines the common PSDs and their influencing factors.

METHODS

Seventy seven qualitative studies identified in a systematic literature review and qualitative data derived from six focus groups are used to generate first-person narratives representing seven brain disorders. A theory-driven thematic analysis of these narratives identifies the PSDs and their influencing factors for comparison between the seven disorders.

RESULTS

First-person narratives illustrate realities for people with brain disorders facilitating a deeper understanding of their every-day life experiences. Thematic analysis serves to highlight the commonalities, both of PSDs, such as loneliness, anger, uncertainty about the future and problems with work activities, and their determinants, such as work opportunities, trusting relationships and access to self-help groups.

CONCLUSIONS

The strength of the methodology and the narratives is that they provide the opportunity for the reader to empathise with people with brain disorders and facilitate deeper levels of understanding of the complexity of the relationship of PSDs, determinants and facilitators. The latter reflect positive aspects of the lives of people with brain disorders. The result that many PSDs and their influencing factors are common to people with different brain disorders opens up the door to the possibility of using cross-cutting interventions involving different sectors. This strengthens the message that 'a great deal can be done' to improve the lived experience of persons with brain disorders when medical interventions are exhausted.

Effects of brain lesions on moral agency: ethical dilemmas in investigating moral behavior

Understanding how the "brain produces behavior" is a guiding idea in neuroscience. It is thus of no surprise that establishing an interrelation between brain pathology and antisocial behavior has a long history in brain research. However, interrelating the brain with moral agency--the ability to act in reference to right and wrong--is tricky with respect to therapy and rehabilitation of patients affected by brain lesions. In this contribution, we outline the complexity of the relationship between the brain and moral behavior, and we discuss ethical issues of the neuroscience of ethics and of its clinical consequences. First, we introduce a theory of moral agency and apply it to the issue of behavioral changes caused by brain lesions. Second, we present a typology of brain lesions both with respect to their cause, their temporal development, and the potential for neural plasticity allowing for rehabilitation. We exemplify this scheme with case studies and outline major knowledge gaps that are relevant for clinical practice. Third, we analyze ethical pitfalls when trying to understand the brain-morality relation. In this way, our contribution addresses both researchers in neuroscience of ethics and clinicians who treat patients affected by brain lesions to better understand the complex ethical questions, which are raised by research and therapy of brain lesion patients.

Psychosocial difficulties in people with epilepsy: a systematic review of literature from 2005 until 2010

The aims of this paper are to identify factors that influence the psychosocial difficulties (PSDs) that persons with epilepsy experience in their everyday life, to describe their onset and the way they evolve over time, and to analyze the determinants of changes over time and other related variables. Electronic databases were searched for studies published in English between January 2005 and May 2010, and information from thirteen studies was extracted. The most frequent PSDs found in people with epilepsy were depressive symptoms, memory functions, quality of life, anxiety, stigma, locus of control, cognitive functions in general, and emotional functions in general. It can be stated that patients' life areas are affected by cognitive, emotional, and psychological problems. However, the majority of studies focus on isolated PSDs or on the effects of a specific determinant in the course of epilepsy, leaving some gaps that could encourage further research.

Epilepsy surgery: how accurate are multidisciplinary teams in predicting outcome?

BACKGROUND

Since epilepsy surgery is an elective procedure, patients need to weigh the risks of the procedure against the likely outcome if they are to make an informed decision to proceed. The aim of this study was to examine the accuracy of multidisciplinary team predictions of postoperative outcome in epilepsy surgery candidates.

METHODS

An experienced multidisciplinary team provided preoperative predictions of postoperative outcome in 94 temporal lobe epilepsy patients who subsequently proceeded to surgery and were followed up one year later.

RESULTS

Team predictions of postoperative outcome were generally accurate for groups of patients judged to have a 30%, 40%, 50% or 60% chance of becoming seizure free. Team estimates of odds tended to regress towards the mean. Logistic regression analyses were more accurate than the team estimates in identifying patients with a very good (>70%) or very poor (<20%) chance of complete seizure freedom. Non localising scalp EEG, necessitating the need for an invasive EEG study prior to surgery was a significant predictor of poor postoperative outcome in this series.

CONCLUSIONS

Probabilities based on logistic regression models may augment and improve the accuracy of clinical estimates of postoperative outcome in patients with a very good or very poor chance of being rendered seizure free by surgery, by counteracting the tendency of regression towards the mean in team decision making.

Current challenges in the practice of epilepsy surgery

The accurate prediction of individual outcomes after epilepsy surgery represents a key challenge facing clinicians. It requires a precise understanding of surgical candidacy and the optimal timing of surgery to maximize a range of outcomes, including medical, psychosocial, cognitive, and psychiatric outcomes. We promote careful consideration of how epilepsy has affected an individual's developmental trajectory as key to constructing more differentiated profiles of postsurgical risk or resilience across multiple outcome measures. This life span approach conceives surgery as a crucial "turning point" in an individual's development from which varied outcome trajectories may follow. This helps clinicians understand the expectations patients and families bring to surgery, and emphasizes the interplay of factors that determine a patient's outcome. It also promotes comprehensive, longitudinal assessment of outcome using data analytical techniques that capture individual differences and identify subgroups with similar trajectories. An ongoing challenge facing clinicians is the development of an outcome classification system that incorporates outcomes other than seizures. We illustrate two emerging areas of research shaping how we define surgical candidacy and predict outcome: (1) using cortico-cortical evoked potentials to identify pathways of seizure propagation and cortico-cortical networks mediating cortical functions, and (2) predicting postoperative depression using a model that incorporates psychosocial and neurobiological factors. The latter research points to the importance of routine follow-up and postoperative psychosocial rehabilitation, particularly in patients deemed at "high risk" for poor outcomes so that early treatment interventions can be implemented. Significantly more research is needed to characterize those patients with poor outcomes who may require re-surgery.

Long-term efficacy and safety of eslicarbazepine acetate: results of a 1-year open-label extension study in partial-onset seizures in adults with epilepsy

PURPOSE

To evaluate the long-term efficacy and safety of once daily eslicarbazepine acetate (ESL) as adjunctive therapy for partial-onset seizures in adults with epilepsy.

METHODS

One-year open-label treatment extension with ESL in patients who completed a placebo-controlled pivotal study (Epilepsia 2009; 50: 454-463). Starting dose was 800 mg once daily, for 4 weeks; thereafter, dose could be titrated up or down. Doses of concomitant antiepileptic drugs were to be kept stable.

RESULTS

Overall, 314 patients were enrolled. The intent-to-treat population consisted of 312 patients, and 239 (76.6%) completed 1 year of treatment. ESL median dose was 800 mg once daily. Compared to baseline, median seizure frequency decreased by 39% during the first 4 weeks and between 48% and 56% thereafter. The responder rate (≥50% seizure reduction) was 41% during weeks 1-4 and, thereafter ranged between 48% and 53%. The proportion of seizure-free patients per 12-week interval ranged between 8.7% and 12.5%. Quality of life, as measured by the Quality of Life in Epilepsy Inventory-31 (QOLIE-31), and depressive symptoms, as measured by the Montgomery Asberg Depression Rating Scale (MADRS), improved significantly compared to baseline. Treatment-emergent adverse events (TEAEs) were reported by 51% of patients. The most frequent TEAEs were headache (10%), dizziness (10%), diplopia (5%), and nasopharyngitis (5%). TEAEs were mostly (97%) of mild to moderate intensity. Eleven patients (3.5%) discontinued due to TEAEs. There were no results of laboratory tests raising safety concerns.

DISCUSSION

Sustained therapeutic effect, favorable tolerability and safety, and an improvement in quality of life and depressive symptoms were observed during long-term add-on treatment of partial-onset seizures in adults with once daily ESL.

The amygdala and anxiety after epilepsy surgery

The relationship between amygdalar volume and anxiety after epilepsy surgery was explored. Participants comprised patients who underwent mesial temporal (n=26) or non-mesial temporal resections (n=16) and 41 neurologically normal controls. Anxiety was prospectively measured preoperatively and for the first 12 months postoperatively using criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Amygdalar volumetry was performed on preoperative and control T1-weighted MRI scans. Resection of an ipsilateral amygdala of normal volume, relative to controls, was associated with postoperative anxiety in patients with mesial temporal resections, regardless of seizure outcome [F(1, 22)=5.17, P<0.05]. There was no relationship between amygdalar volume and anxiety in patients with non-mesial temporal resections, or between contralateral amygdalar volume and anxiety in patients with mesial temporal resections (P>0.05 for all comparisons). In conclusion, resection or deafferentation of an amygdala with a volume within the normal range was associated with increased postoperative anxiety.

Quality of life after surgery for temporal lobe epilepsy: a 5-year follow-up

The authors carried out a 5-year prospective study about the effects epilepsy surgery can have on a patient's quality of life (QOL). They looked for the relationship between improvement on QOL after surgery and reduction of seizure frequency, seizure focus, age at surgery and previous psychopathology. They concluded that improvement in overall, cognitive and social function scores were statistically significant throughout the study. Seizure worry score ceased to be significant at the fifth year. Previous psychopathology was a negative influence on social and seizure worry score. Compared to left lobectomies, right lobectomies showed significant better results in overall scores at six months and one year follow-up. At 1 month follow-up, cognitive function was also significantly better in right lobectomies. Engels class I patients demonstrated statistically better results in the fourth and fifth years of follow-up. Neither years of disease nor patient age at surgery seemed to influence QOL.

The experience of seizures after epilepsy surgery

Postoperative seizures occur in 20-60% of patients who have epilepsy surgery. Despite this, there is limited understanding of a patient's experience of the recurrence of seizures after surgery. This study used a qualitative approach to identify key themes derived from content analysis of 15 in-depth patient interviews about the experience of seizure recurrence. The results showed a prominence of psychological issues over medical concerns. The four most frequently expressed themes were perceived success of surgery, medication, acceptance of seizure recurrence, and personal independence. Despite seizure recurrence, patient sentiments were not universally negative; rather there was heterogeneity of views, with some reporting ambivalence and others a sense of satisfaction with outcome. The findings provide evidence for the importance of cognitive reframing and benefit finding in the context of seizure recurrence.

Life adjustment after surgical treatment for temporal lobe epilepsy

OBJECTIVE: The purpose of this study was to evaluate the patients' life adjustment after epilepsy surgery, through instruments of quality of life (QoL), anxiety, depression, preoperative expectations and postoperative life changing. METHODS: Thirty-six adults who underwent temporal lobe epilepsy surgery were interviewed before surgery, and 6 and 12 months after surgery. RESULTS: For all patients, epilepsy surgery gave rise to an evolving process of postoperative adjustment, what means that they were satisfied with surgery results, and that their expectations were reached. The improvement was seen in their QoL (p=0.004), anxiety (p=0.019) and depression (p=0.001), which was associated to their perception of positive life changing. The inexistence of depressive and anxiety symptoms and the good QoL after surgery predicted the perception of positive life changing. This study could predict a total of 56.5% of aspects involved in the perception of positive life changing after epilepsy surgery, what seems that other variables may be involved in this process. The patients' status before surgery (expectations, QoL, anxiety, depression and seizures frequency) did not predict the life satisfaction after surgery, what means that when patients evaluate their actual lives they do it looking for daily aspects and do not tend to compare to their lives before surgery. CONCLUSION: The findings of the present study have implications for the evaluation of life adjustment postsurgery, calling attention to measures of preoperative expectations, anxiety, depression and QoL. The strength of these contributions highlights the importance of registering the patients' feelings and opinions during the presurgical evaluation and may help the health providers to understand the aspects necessary to improve the patients' quality of life.

Employment and quality of life in mesial temporal lobe epilepsy with hippocampal sclerosis: is there a change after surgical treatment?

PURPOSE: The aim of this study was to evaluate in patients with mesial temporal lobe epilepsy (MTLE) with hippocampal sclerosis (HS): (1) employment patterns before and three years after epilepsy surgery and their impact in Quality of Life (QOL); (2) demographic and clinical variables associated with employment. METHODS: Data from 58 patients with diagnosis of refractory MTLE with HS who had corticoamygdalo-hippocampectomy were analyzed. The subjects answered to Brazilian validated version of the Epilepsy Surgery Inventory (ESI-55) before, and three years after surgery. In a semi-structured interview, sociodemographic and clinical characteristics were obtained. Changes in employment after surgery were classified in one of the three categories: (i) improvement status: those who were unemployed, no-formal employed, students, housewives and subjects who have never worked to employed category; (ii) unchanged status: no change in occupation; this category included subjects who were employed before and after the surgery, housewives, students, and the group who remained unemployed, receiving ill-health benefits or retired after the surgical treatment; and (iii) worsened status: loss of employment. RESULTS: Employment status did not show any significant change after surgery: in 51(87.9%) it remained unchanged, in six (10.3%) it improved, and one patient (1.7%), who was employed before the surgery, retired after that. In a subgroup of 22 patients employed after surgery, ten (45.5%) were seizure-free, seven (31.8%) had only rare auras, and five (22.7%) had seizures. In the group of improvement, 12 patients (70.5%) had no-formal employment and five (29.5%) had a formal job before surgery. After three years, 14 (63.6%) of 22 subjects were formally employed. Our data suggested that the employability was strongly correlated (p<0.05) with a positive perception of health-related quality of life measured by ESI-55, before and after surgical evaluation. CONCLUSION: Our study demonstrated in a homogeneous group of MTLE with HS, a modest, but positive relationship between surgical outcome and work gain, and that QOL had strong correlation with the fact of being employed.

The contribution of seizures to psychosocial ill-health

Persons with a chronic health condition may be disadvantaged compared to others, though the precise pattern of disadvantage will vary from one condition to another. Persons with epilepsy have been shown to be at increased risk of both psychological morbidity and social disadvantage. Various clinical characteristics of epilepsy have been linked to these psychosocial risks, primary among which is seizure frequency: studies linking seizure frequency to psychosocial ill-health are reviewed here. Given the apparently powerful influence of seizure frequency, it is unsurprising that psychosocial health trajectories in epilepsy are very closely linked to its clinical course-but the relationship is not a completely linear one. Recent research has begun to unravel factors other than seizure frequency which appear promoting or protective of psychosocial ill-health. The need for a more nuanced approach to understanding the causes of psychosocial ill-health is highlighted, as is an important distinction between epilepsy as biomedically defined disease and as socially defined illness.

Quality-of-life trajectories in epilepsy: a review of the literature

The potential psychosocial sequelae of epilepsy are well-documented, but it cannot be assumed that trajectories for quality of life (QOL) of people with epilepsy will inevitably follow its clinical course. In this article, we draw on available literature to suggest likely QOL trajectories associated with epilepsy and the broad range of disease-, patient-, and other-focused factors that appear important in determining them. We conclude that both the likely shape and time frame for QOL trajectories associated with particular clinical scenarios can be delineated, but that their shape can be altered by a much wider range of factors than those represented as epilepsy disease progression. We identify contributory factors currently relatively unexplored and highlight implications for treatment and areas for future research.

Employment outcomes following resective epilepsy surgery

PURPOSE

Analyze determinates of employment changes from before to 2 years after surgery in refractory focal epilepsy patients.

METHODS

Preoperative employment was prospectively assessed in 375 adults with refractory epilepsy. Two-year postsurgical employment status was obtained for 299; factors potentially associated with employment status change among subgroups unemployed and employed at baseline were analyzed.

RESULTS

Presurgical employment status was full-time (n = 148, 39.5%), part-time (n = 26, 6.9%), disabled and unemployed (n = 100, 26.7%), unemployed (n = 44, 11.7%), and other (n = 57, 15.2%). Those with and without 2-year follow-up did not differ on baseline characteristics (all p > 0.10). Two years after surgery, 42.8% were employed full-time and 12.4%, part-time. Among those unemployed before surgery, better seizure outcome was associated with gaining employment at 2 years (p = 0.03).

CONCLUSIONS

Net employment gains were modest 2 years after surgery and higher with better seizure outcomes, reinforcing the need for optimizing surgical candidate selection, long-term follow-up studies, and postsurgical vocational rehabilitation.

Psychosocial adjustment following relief of chronic narcolepsy

BACKGROUND AND PURPOSE

No previous research has examined the psychosocial adjustment of chronic narcolepsy patients following efficacious pharmacotherapy. In contrast, considerable research has examined the process of psychosocial adjustment following surgical relief of chronic epilepsy. This process can manifest as a clinical syndrome, the 'burden of normality', comprising psychological, behavioural, affective and sociological features. The aim of the present study was to characterise the process of psychosocial adjustment of patients with successfully treated narcolepsy and to explore the applicability of the burden of normality.

PATIENTS AND METHODS

Thirty-three narcolepsy patients and 31 epilepsy surgery patients were recruited through routine outpatient follow-up at the Austin Hospital in Melbourne. All patients underwent in-depth, qualitative psychosocial assessment using a well-validated semi-structured interview, the Austin CEP Interview. They were also administered quantitative measures of anxiety (State Trait Anxiety Inventory) and depression (Beck Depression Inventory-II).

RESULTS

Narcolepsy patients spontaneously reported similar themes of post-treatment adjustment to successfully treated epilepsy patients, including symptoms of the burden of normality. Chi-squared analyses revealed that the two groups differed only on disease-specific factors, reflecting the later diagnosis and treatment of narcolepsy (P<0.05).

CONCLUSION

The results support a general model of adjustment following successful treatment of chronic neurological illness, as the patient discards perceptions of illness and behaviours associated with being 'sick' and learns to become 'well'. Recognition of the burden of normality has important clinical implications for maximising the post-treatment care and outcome of narcolepsy patients.

The psychological impact of a newly diagnosed seizure: losing and restoring perceived control

This study aimed to characterize the process of psychosocial adjustment following a newly diagnosed seizure. Eighty-five adult patients were assessed 1 and 3 months after a first seizure presentation with a purpose-developed semistructured interview, the NEWQOL, and the COPE. Among a broad range of patient concerns, psychological issues were paramount, representing a process of losing and restoring perceived control. Two psychological adjustment trajectories were identified, which hinged on the experience of a limited (n=37) or pervasive (n=48) loss of control. These adjustment trajectories were predicted by demographic and clinical factors. The pervasive group described a more extensive process of reevaluation, leading to an improved sense of self at 3 months. Pervasive loss of control, anxiety, and depression predicted subsequent seizure recurrence. Overall, a first seizure can trigger a complex adjustment process, which might require therapeutic management in some patients.