Psychotic disorders in Argentine patients with refractory temporal lobe epilepsy: a case-control study

Psychiatric disorders, depression and quality of life in patients with psychogenic non-epileptic seizures and drug resistant epilepsy living in Argentina

OBJECTIVES

Psychiatric disorders are frequently found in both patients with PNES and DRE, making the differential diagnosis even more complex. The aim of this study was to analyze and compare psychiatric aspects and the quality of life in patients with psychogenic non-epileptic seizures (PNES) and drug resistant epilepsy (DRE).

METHODS

Patients admitted to video-electroencephalograpy (VEEG) unit with confirmed PNES and DRE were included. Demographical characteristics, psychiatric diagnosis according to SCID I and II of DSM IV, pharmacological treatment, general functioning measured with GAF (Global assessment of functionality), quality of life (QoL) using QlesQSF (Quality of Life Enjoyment and Satisfaction Questionnaire Short Form) and depression severity using BDI II (Beck depression inventory), were compared between the groups. Non-parametric tests, chi square test, and logistic regression were used for statistical analysis.

RESULTS

148 patients consecutively admitted to VEEG were included (DRE n = 97; PNES n = 51). Somatization disorder (RR: 13.02, 95% CI: 1.23-137.39, p = 0.03) and a history of trauma (RR: 8.66, 95% CI: 3.21-23.31, p = 0.001) were associated with PNES. The QlesQ score and the GAF score were lower with a higher prevalence of suicide attempts in the PNES group (p < 0.01). A negative correlation was observed between the severity of depression and the quality of life (DRE r = - 0.28, p = 0.013; PNES r = - 0.59, p = 0.001).

CONCLUSIONS

Higher psychiatric comorbidity with poorer QoL were found in PNES patients compared to DRE. However, depression comorbidity negatively affected the QoL in both groups. Future studies based on illness perception will be orientated to complete this analysis.

Reduced expression of the glucocorticoid receptor in the hippocampus of patients with drug-resistant temporal lobe epilepsy and comorbid depression

Objective

Depressive disorders are common among about 50% of the patients with drug‐resistant temporal lobe epilepsy (TLE). The underlying etiology remains elusive, but hypothalamus‐pituitary‐adrenal (HPA) axis activation due to changes in glucocorticoid receptor (GR) protein expression could play an important role. Therefore, we set out to investigate expression of the GR in the hippocampus, an important brain region for HPA axis feedback, of patients with drug‐resistant TLE, with and without comorbid depression.

Methods

GR expression was studied using immunohistochemistry on hippocampal sections from well‐characterized TLE patients with depression (TLE + D, n = 14) and without depression (TLE − D, n = 12) who underwent surgery for drug‐resistant epilepsy, as well as on hippocampal sections from autopsy control cases (n = 9). Video–electroencephalography (EEG), magnetic resonance imaging (MRI), and psychiatric and memory assessments were performed prior to surgery.

Results

Abundant GR immunoreactivity was present in dentate gyrus granule cells and CA1 pyramidal cells of controls. In contrast, neuronal GR expression was lower in patients with TLE, particularly in the TLE + D group. Quantitative analysis showed a smaller GR+ area in TLE + D as compared to TLE − D patients and controls. Furthermore, the ratio between the number of GR+/NeuN+ cells was lower in patients with TLE + D as compared to TLE − D and correlated negatively with the depression severity based on psychiatric history. The expression of the GR was also lower in glial cells of TLE + D compared to TLE − D patients and correlated negatively to the severity of depression.

Significance

Reduced hippocampal GR expression may be involved in the etiology of depression in patients with TLE and could constitute a biological marker of depression in these patients.

Depression and Temporal Lobe Epilepsy: Expression Pattern of Calbindin Immunoreactivity in Hippocampal Dentate Gyrus of Patients Who Underwent Epilepsy Surgery with and without Comorbid Depression

Purpose

Changes in calbindin (CB) expression have been reported in patients with temporal lobe epilepsy (TLE) with controversial implications on hippocampal functions. The aim of this study was to determine the CB immunoreactivity in hippocampal dentate gyrus of patients who underwent epilepsy surgery for drug-resistant TLE with and without comorbid depression and/or memory deficits.

Methods

Selected hippocampal samples from patients with TLE who underwent epilepsy surgery were included. Clinical and complementary assessment: EEG, video-EEG, MRI, psychiatric assessment (structured clinical interview, DSM-IV), and memory assessment (Rey auditory verbal learning test, RAVLT; Rey-Osterrieth complex figure test, RCFT), were determined before surgery. Hippocampal sections were processed using immunoperoxidase with the anti-calbindin antibody. The semiquantitative analysis of CB immunoreactivity was determined in dentate gyrus by computerized image analysis (ImageJ).

Results

Hippocampal sections of patients with TLE and HS (n = 24) and postmortem controls (n = 5) were included. A significant reduction of CB+ cells was found in patients with TLE (p < 0.05, Student's t-test). Among TLE cases (n = 24), depression (n = 12) and memory deficit (n = 17) were determined. Depression was associated with a higher % of cells with the CB dendritic expression (CB-sprouted cells) (F(1, 20) = 11.81, p = 0.003, hp² = 0.37), a higher CB+ area (μm²) (F(1, 20) = 5.33, p = 0.032, hp² = 0.21), and a higher optical density (F(1, 20) = 15.09, p = 0.001, hp² = 0.43) (two-way ANOVA). The GAF scale (general assessment of functioning) of DSM-IV inversely correlated with the % of CB-sprouted cells (r = −0.52, p = 0.008) and with the CB+ area (r = −0.46, p = 0.022).

Conclusions

In this exploratory study, comorbid depression was associated with a differential pattern of CB cell loss in dentate gyrus combined with a higher CB sprouting. These changes may indicate granular cell dysmaturation associated to the epileptic hyperexcitability phenomena. Further investigations should be carried out to confirm these preliminary findings.

How Different Are the Patients With Bilateral Hippocampal Sclerosis From the Unilateral Ones Clinically?

PURPOSE

There is a lack of knowledge on consecutive patients with epilepsy associated with bilateral hippocampal sclerosis (BHS). We aimed to investigate the differentiating features of BHS in comparison with unilateral HS (UHS).

METHOD

We investigated our database for patients with epilepsy fulfilling the major magnetic resonance imaging criteria for BHS; namely, presence of bilateral atrophy and high signal changes on T2 and FLAIR series in the hippocampi. UHS patients seen in past 2 years were included as the control group. Clinical, EEG, and other laboratory findings, data on treatment response and epilepsy surgery were investigated from their files.

RESULTS

A total of 124 patients (31 with BHS and 93 with UHS; 49 right-sided and 44 left-sided) were included. We found that 16.1% of the BHS and 18.3% of the UHS groups were not drug-refractory. A binary logistic regression analysis performed with significant clinical features disclosed that history of febrile status epilepticus, mental retardation, and status epilepticus were statistically more common in BHS group. Moreover, diagnosis of psychosis established by an experienced psychiatrist and slowing of the EEG background activity were both found significantly more frequent in BHS. 66.67% of the operated BHS patients showed benefit from epilepsy surgery.

CONCLUSIONS

BHS is a heterogeneous group, showing significant differences such as increased frequencies of mental retardation, status epilepticus, febrile status epilepticus and psychosis, in comparison to UHS. In all, 16.1% of the BHS cases showed a benign course similar to the UHS group and some patients with drug-resistant epilepsy may show benefit from epilepsy surgery.

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

OBJECTIVES

Temporal lobe resistant epilepsy has been associated with a high incidence of psychotic disorders; however, there are many controversies; while some patients get better after surgery from their psychiatric condition, others develop psychosis or de novo depression. The aim of this study was to determine the psychiatric and seizure outcome after epilepsy surgery in patients with a previous history of psychoses.

METHODS

Surgical candidates with temporal lobe drug-resistant epilepsy and a positive history of psychosis diagnosed during the presurgical psychiatric assessment were included. A two-year prospective follow-up was determined after surgery. The DSM-IV Structural Interview, GAF (global assessment of functionality, DSM-IV), Ictal Classification for psychoses, and Engel's classification were used. The Student t test and chi-square-Fisher tests were used.

RESULTS

During 2000-2010, 89 patients were admitted to the epilepsy surgery program, 14 patients (15.7%) presented psychoses and were included in this series. After surgery, six patients (43%) did not develop any psychiatric complications, three patients (21%) with chronic interictal psychosis continued with no exacerbation, three patients (21%) developed acute and transient psychotic symptoms, and two patients (14%) developed de novo depression. Seizure outcome was Engel class I-II in 10 patients (71%). Total GAF scores were higher after surgery in patients found to be in Engel class I-II (p<0.05).

CONCLUSIONS

Patients with comorbid psychosis and temporal lobe drug-resistant epilepsy may benefit from epilepsy surgery under close psychiatric supervision.

Psychiatric disorders in patients with psychogenic nonepileptic seizures and drug-resistant epilepsy: a study of an Argentine population

Epidemiological data show that up to 20-30% of patients with psychogenic nonepileptic seizures (PNESs), resembling drug-resistant epilepsy (DRE), are referred to tertiary epilepsy centers. Furthermore, both disorders present high psychiatric comorbidity, and video-EEG is the gold standard to make differential diagnoses. In this study, we described and compared the clinical presentation and the frequency of psychiatric disorders codified in DSM IV in two groups of patients, one with PNESs and the other with DRE, admitted in a tertiary care epilepsy center of Buenos Aires, Argentina. We included 35 patients with PNESs and 49 with DRE; all were admitted in the video-EEG unit in order to confirm an epilepsy diagnosis and determine surgical treatment possibilities. All patients underwent a neurological and psychiatric assessment, according to standardized protocol (SCID I and II; DSM IV criteria). Student's t test was performed to compare continuous variables and Chi square test to compare qualitative variables. In this study, 33 (67%) patients with DRE and 35 (100%) patients with PNESs met criteria for at least one disorder codified in Axis I of DSM IV (p=0.003). Differences in the frequency of psychiatric disorder presentation were found between groups. Anxiety disorders (16.32% vs 40%; p=0.015), trauma history (24.5% vs 48.57%; p=0.02), posttraumatic stress disorder (4.08% vs 22.85%; p=0.009), and personality cluster B disorders (18.37% vs 42.86%; p=0.02) were more frequent in the group with PNESs. Psychotic disorders were more frequent in the group with DRE (20.4% vs 2.85%; p=0.019). Depression was equally prevalent in both groups. Standardized psychiatric assessment provides information that could be used by the mental health professional who receives the referral in order to improve quality of care and smooth transitions to proper PNES treatment, which should include a multidisciplinary approach including neurology and psychiatry.

Psychosis after epilepsy surgery: report of three cases

Temporal lobe epilepsy surgery has become a successful alternative in patients with refractory epilepsy. However, the outcome of epilepsy surgery may be affected by the occurrence of postsurgical psychiatric symptoms, such as psychosis. This report describes three cases of refractory temporal lobe epilepsy and hippocampal sclerosis, which, after anterior temporal lobectomy, presented with acute psychosis. One of them had a history of acute psychosis, and all of them met criteria for Cluster A personality disorder (schizoid/schizotypal) during psychiatric assessment prior to surgery. The three cases had a good seizure outcome (Engel I), but, on follow-up during the first year after surgery, developed an acute psychotic episode compatible with schizoaffective disorder; brief psychotic disorder; and a delusional disorder, respectively, according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Treatment with low-dose risperidone was successful.

Disease duration and arcuate fasciculus abnormalities correlate with psychoticism in patients with epilepsy

PURPOSE

We sought to investigate the relationship between interictal personality changes and white matter abnormalities in epilepsy patients.

METHODS

A total of 65 individuals with epilepsy and 40 demographically matched controls were evaluated by Eysenck Personality Questionnaire (EPQ) and diffusion tensor imaging (DTI) on 3T. Fractional anisotropy (FA) values of fibers were acquired. The relationship between EPQ scores, clinical variables and FA values was confirmed by Pearson correlation analysis and multiple linear regression analysis.

RESULTS

Epilepsy patients had higher psychoticism scores (P score) and lower extraversion scores (E score) compared with controls. P scores were higher in patients with long duration (>10 years) and taking multiple antiepileptic drugs. No difference was found in E score according to all the clinical variables. Epilepsy patients showed significantly lower mean FA value compared with healthy controls in the bilateral uncinate fasciculus, cingulum bundle, arcuate fasciculus and forceps minor of the corpus callosum. Multivariate linear regression analysis revealed that duration of epilepsy and FA value of the right arcuate fasciculus was independent risk factors of psychoticism in epilepsy patients.

CONCLUSIONS

Long disease duration and impairment of arcuate fasciculus integrity may predispose the development of psychoticism in patients with epilepsy. Our results provide important insights into the pathophysiological mechanisms underlying personality change in epilepsy.

Doublecortin (DCX) immunoreactivity in hippocampus of chronic refractory temporal lobe epilepsy patients with hippocampal sclerosis

INTRODUCTION

Status epilepticus increases the production of new neurons (hippocampal neurogenesis) and promotes aberrant migration. However chronic experimental models of epilepsy and studies performed in human epilepsy showed controversial results suggesting a reduction in hippocampal neurogenesis in late stages of the disease. Doublecortin (DCX) has been validated to determine alterations in the production of new neurons in the human hippocampus.

OBJECTIVES

Determine DCX expression in human hippocampal sclerosis (HS) from patients who underwent epilepsy surgery for refractory temporal lobe epilepsy (TLE).

METHODS

Hippocampal sections of 9 patients with HS and TLE who underwent surgery, were processed using immunoperoxidase for DCX. Archival material from 5 normal post-mortem hippocampus were simultaneously processed.

RESULTS

Significantly lower staining intensity was observed in DCX-positive neurons localized in dentate gyrus (DG) and in CA1 of epileptic hippocampus; lower DCX reactive area was observed in pyramidal layers of CA1; and a reduced in the mean number of DCX-positive neurons were determined in DG compared to normal hippocampus (p<0.05).

CONCLUSIONS

This study found a decrease in DCX expression in hippocampus of patients with HS and chronic and refractory TLE suggesting alterations in NG and hippocampal synaptogenesis with potential cognitive and emotional repercussion.