Post-traumatic stress disorder (PTSD) in patients with epilepsy

Post-Traumatic Stress-Disorder in Epilepsy: Meta-analysis of current evidence

Epilepsy, a chronic neurological condition characterized by unpredictable seizures, poses considerable challenges, including disability, stigma, and increased mortality. Psychiatric comorbidities are prevalent in 20-30% of epilepsy patients, notably mood or anxiety disorders, psychotic symptoms, and personality disorders. Trauma and childhood adversities are pivotal risk factors for psychopathology, yet the link between Post-Traumatic Stress Disorder (PTSD) and epilepsy remains underexplored. This meta-analysis is aimed to establish updated estimates of PTSD prevalence among individuals with epilepsy. Fifteen studies, comprising 996 epilepsy patients, were included. The overall pooled prevalence of PTSD in epilepsy patients was 18%. Notably, patients with epilepsy exhibited a three-fold increased risk of developing PTSD compared to the general population. Subgroup analysis revealed a higher PTSD prevalence in uncontrolled studies (25%) compared to controlled studies (14%). Additionally, patients with Psychogenic Non-Epileptic Seizures (PNES) demonstrated higher PTSD prevalence than epilepsy patients, with a threefold higher risk in healthy controls compared to PNES controls. While gender prevalence did not significantly affect PTSD occurrence, drug resistant epilepsy did not correlate with PTSD prevalence. Moreover, age of epilepsy onset showed no significant correlation with PTSD prevalence. This meta-analysis underscores the substantial burden of PTSD among epilepsy patients, potentially attributable to the traumatic nature of seizures and the chronic stigma associated with epilepsy. Improved recognition and management of psychiatric conditions, particularly PTSD, are crucial in epilepsy care pathways to enhance patients' quality of life. Further research and comprehensive diagnostic tools are imperative to better understand and address the prevalence of PTSD in epilepsy patients.

The prevalence and correlates of PTSD, insomnia, and fatigue among people with epilepsy during Oct.7th war on Gaza: A study from Jordan

Jordan and Palestine are tightly related countries as the same families live in the two adjacent countries. The present study sought to examine the prevalence and determinants of Post-Traumatic Stress Disorder (PTSD)symptoms, insomnia, and fatigue among a cohort of People with Epilepsy (PWE) in Jordan. This is a cross-sectional study with inclusion criteria. PTSD, insomnia, and fatigue were assessed using validated scales. Data were analyzed from 109 PWE, PTSD symptoms were screened in (35.5 %), and Insomnia was screened in 51.8 %, moreover, fatigue mean score ± SD was 44.64 ± 26.96. PTSD symptoms were significantly associated with "females" and "age above 30 years" Insomnia severity was associated with "females". Also, the regression results demonstrated that "abstinence from social media" was significantly related to lower insomnia severity. Higher fatigue severity was associated with "married" and "Generalized Tonic-Clonic Seizures", whereas, lower fatigue severity was associated with "males", and with "levetiracetam". Our findings indicate the need for actions to alleviate mental health deterioration in PWE.

Stress and Epilepsy: Towards Understanding of Neurobiological Mechanisms for Better Management

Stress has been identified as a major contributor to human disease and is postulated to play a substantial role in epileptogenesis. In a significant proportion of individuals with epilepsy, sensitivity to stressful events contributes to dynamic symptomatic burden, notably seizure occurrence and frequency, and presence and severity of psychiatric comorbidities [anxiety, depression, posttraumatic stress disorder (PTSD)]. Here, we review this complex relationship between stress and epilepsy using clinical data and highlight key neurobiological mechanisms including the hypothalamic-pituitary-adrenal (HPA) axis dysfunction, altered neuroplasticity within limbic system structures, and alterations in neurochemical pathways such as brain-derived neurotrophic factor (BNDF) linking epilepsy and stress. We discuss current clinical management approaches of stress that help optimize seizure control and prevention, as well as psychiatric comorbidities associated with epilepsy. We propose that various shared mechanisms of stress and epilepsy present multiple avenues for the development of new symptomatic and preventative treatments, including disease modifying therapies aimed at reducing epileptogenesis. This would require close collaborations between clinicians and basic scientists to integrate data across multiple scales, from genetics to systems biology, from clinical observations to fundamental mechanistic insights. In future, advances in machine learning approaches and neuromodulation strategies will enable personalized and targeted interventions to manage and ultimately treat stress-related epileptogenesis.

Post-traumatic stress disorder (PTSD), cognitive control, and perceived seizure control in patients with epilepsy: An exploratory study

Epilepsy is often linked to various psychiatric symptoms, with anxiety, depression, and interictal dysphoric disorders being the most prevalent. Few studies have investigated posttraumatic stress disorder (PTSD) in epilepsy, but they suggest a notable prevalence of PTSD. PTSD is known to be associated with cognitive impairments, particularly memory and executive functions. Our proposed exploratory study aims to investigate executive attentional control and emotional inhibition in patients with drug-resistant epilepsy (DRE) who exhibit PTSD symptoms compared with a healthy control group. Additionally, some PWE can manage their seizures using emotional and cognitive strategies, we find it relevant to explore the connection between their regulation abilities, cognitive control performance, and PTSD symptoms. We included 54 PWE and 60 healthy participants. They completed anxiety and depression scales as well as two questionnaires assessing PTSD symptoms and a questionnaire that measured the perceived self-control of seizures. We measured executive control using an executive control task (Attention Network Test, ANT) and an emotional Go/No-Go task. We found a positive correlation between PTSD scores (PDS-5) and performance at the ANT task. In contrast, in the emotional inhibition (Go/No-Go) task, behavioral inhibition errors were positively correlated with PTSD scores, specifically with hypervigilance symptoms in PTSD+ patients. There was a positive correlation between response reaction times in an aversive condition and PTSD scores: the more severe the PTSD symptoms, the faster the PWE identified stimuli in the angry face condition of the Go/No-Go task. Regarding perceived seizure control, we found correlations between alertness and PTSD symptoms associated with seizure anticipation during the inter- and peri-ictal periods. Patients with PTSD symptoms reported better seizure control. Our findings suggest that epilepsy patients with PTSD experience cognitive changes such as heightened executive attentional control, weakened emotional inhibition, and improved seizure control perception.

BDNF as potential biomarker of epilepsy severity and psychiatric comorbidity: pitfalls in the clinical population

BACKGROUND

Several studies implicate brain-derived neurotrophic factor (BDNF) in the pathophysiology of epilepsy. In particular, preclinical data suggest that lower serum BDNF is a biomarker of epilepsy severity and psychiatric comorbidities. We tested this prediction in clinical epilepsy cohorts.

METHODS

Patients with epilepsy were recruited from 4 epilepsy centers in France and serum BDNF was quantified. Clinical characteristics including epilepsy duration, classification, localization, etiology, seizure frequency and drug resistance were documented. Presence of individual anti-seizure medications (ASM) was noted. Screening for depression and anxiety symptoms was carried out in all patients using the NDDI-E and the GAD-7 scales. In patients with positive screening for anxiety and/or depression, detailed psychiatric testing was performed including the Mini International Neuropsychiatric Interview (MINI), STAI-Y, Holmes Rahe Stressful Events Scale and Beck Depression Interview. Descriptive analysis was applied. Spearman's test and Pearson's co-efficient were used to assess the association between BDNF level and continuous variables. For discrete variables, comparison of means (Student's t-test, Mann-Whitney u-test) was used to compare mean BDNF serum level between groups. Multivariate analysis was performed using a regression model.

RESULTS

No significant correlation was found between serum BDNF level and clinical features of epilepsy or measures of depression. The main group-level finding was that presence of any ASM at was associated with increased BDNF; this effect was particularly significant for valproate and perampanel.

CONCLUSION

Presence of ASM affects serum BDNF levels in patients with epilepsy. Future studies exploring BDNF as a possible biomarker of epilepsy severity and/or psychiatric comorbidity must control for ASM effects.

Dissociation in patients with epilepsy and functional seizures: A narrative review of the literature

Dissociation is a "disruption of the usually integrated functions of consciousness, memory, identity or perception of the environment" according to DSM-5.  It is commonly seen in psychiatric disorders including primary dissociative disorders, post-traumatic stress disorder, depression, and panic disorder. Dissociative phenomena are also described in the context of substance intoxication, sleep deprivation and medical illnesses including traumatic brain injury, migraines, and epilepsy. Patients with epilepsy have higher rates of dissociative experiences as measured on the Dissociative Experiences Scale compared to healthy controls. Ictal symptoms, especially in focal epilepsy of temporal lobe origin, may include dissociative-like experiences such as déjà vu/jamais vu, depersonalization, derealization and what has been described as a "dreamy state".  These descriptions are common in the setting of seizures that originate from mesial temporal lobe epilepsy and may involve the amygdala and hippocampus. Other ictal dissociative phenomena include autoscopy and out of body experiences, which are thought to be due to disruptions in networks responsible for the integration of one's own body and extra-personal space and involve the temporoparietal junction and posterior insula. In this narrative review, we will summarize the updated literature on dissociative experiences in epilepsy, as well as dissociative experiences in functional seizures. Using a case example, we will review the differential diagnosis of dissociative symptoms. We will also review neurobiological underpinnings of dissociative symptoms across different diagnostic entities and discuss how ictal symptoms may shed light on the neurobiology of complex mental processes including the subjective nature of consciousness and self-identity.

Seizures as a Struggle between Life and Death: An Existential Approach to the Psychosocial Impact of Seizures in Candidates for Epilepsy Surgery

INTRODUCTION

Mental health comorbidities such as depression and anxiety are common in epilepsy, especially among people with pharmacoresistant epilepsy who are candidates for epilepsy surgery. The Psychology Task Force of the International League Against Epilepsy advised that psychological interventions should be integrated into comprehensive epilepsy care.

METHODS

To better understand the psychological impact of epilepsy and epileptic seizures in epilepsy surgery candidates, we analysed interviews with this subgroup of patients using Karl Jaspers' concept of limit situations, which are characterised by a confrontation with the limits and challenges of life. These are especially chance, randomness, and unpredictability, death and finitude of life, struggle and self-assertion, guilt, failure, and falling short of one's aspirations.

RESULTS

In 43 interviews conducted with 15 people with drug-resistant epilepsy who were candidates for epilepsy surgery, we found that these themes are recurrent and have a large psychosocial impact, which can result in depression and anxiety. For some people, epileptic seizures appear to meet the criteria for traumatic events.

CONCLUSION

Understanding epilepsy and seizures as existential challenges complements the neurobiological explanations for psychological comorbidities and can help tailor psychological interventions to the specific needs of people with epilepsy, especially those who are candidates for surgical treatment.

Fear of sleep in people with epilepsy

More than one third of people with epilepsy (PWE) report experiencing insomnia. This is highly concerning given that sleep loss both triggers and exacerbates seizures. It is therefore paramount that we understand the underlying mechanisms of insomnia in PWE. Nevertheless, research in this area remains limited, with little understanding of the emerging or maintaining factors of insomnia in PWE. Therefore, the current study sought to explore fear of sleep as a novel explanation for the increased rate of insomnia in PWE, and whether fear of sleep was related to post-seizure trauma. We recruited 184 PWE and 197 healthy controls via social media and collected data using a series of online questionnaires. We found that fear of sleep did not significantly differ between the epilepsy and control group. In the epilepsy group, fear of sleep seemed to be largely driven by trauma, especially post-seizure trauma but also non-seizure related trauma, along with anxiety and higher seizure frequency. Fear of sleep in the control group was also largely driven by trauma, but also anxiety and depression. Finally, we found more severe and prevalent insomnia in PWE relative to controls, and in both groups, fear of sleep was the most significant contributor to insomnia. Our novel findings carry important clinical implications. First, they point to the central role of trauma in fear of sleep not only in PWE but also in the general population. Our findings also indicate that fear of sleep is an important maintaining factor of insomnia. Ultimately, these results suggest that all individuals with insomnia may benefit from insomnia interventions targeted at trauma, depression, anxiety, and fear of sleep. PWE are likely to benefit from additional treatment components for seizure-related trauma and seizure management. To better understand the reliability and generalisability of our novel findings, future research should further assess fear of sleep and its role in maintaining insomnia in the epilepsy population.

Psychiatric co-morbidity of drug-resistant epilepsy in Veterans

OBJECTIVE

Psychiatric conditions are frequently co-morbid in epilepsy and studies examining Veterans with epilepsy suggest this population may present with unique psychiatric and clinical features Drug-resistant epilepsy (DRE) may confer a greater risk of psychiatric dysfunction; however, there is a paucity of literature documenting this. To expand our clinical understanding of Veterans with DRE, we assessed a comprehensive Veterans Health Administration (VHA)-wide sample, describing psychiatric conditions, medications, and healthcare utilization.

METHODS

Psychiatric and hospitalization data were collected on 52,579 Veterans enrolled in VHA healthcare between FY2014-2ndQtr.FY2020 from the VHA Corporate Data Warehouse administrative data. Data examined include psychiatric diagnosis, psychotropic medication use, and utilization of hospital services.

RESULTS

At least one psychiatric diagnosis was present in 70.2% of patients, while 49.8% had two or more diagnoses. Depression (51.7%), posttraumatic stress disorder (PTSD) (38.8%), and anxiety (38.0%) represented the most common psychiatric co-morbidities. Psychiatric medication use was present in 73.3%. Emergency room (ER) visits were highest in those with suicidality (mean 14.9 visits), followed by bipolar disorder (10.3), and schizophrenia (12.1). Psychiatric-related hospitalizations were highest for schizophrenia (mean 2.5 admissions) and bipolar disorder (2.3). Females had more psychiatric diagnoses (2.4 vs. 1.6, p < 0.001), psychiatric medications (3.4 vs. 2.3, p < 0.001), and ER utilization than males (6.9 vs. 5.5, p < 0.001).

SIGNIFICANCE

A substantial psychiatric burden exists among Veterans with DRE. Compared to prior epilepsy literature, results suggest that Veterans with DRE evidence more prevalent psychiatric comorbidity, emergency care usage, and inpatient psychiatric admissions. Females were especially impacted, with greater rates of psychiatric conditions and treatment. Considering the relationship of psychiatric comorbidities in epilepsy with psychosocial functioning and quality of life, our findings highlight the need for screening and provision of services for those with DRE.

"What is this strange sensation?" A qualitative exploration of metaphors used to verbalise hard-to-describe experiences by people with epilepsy

Mental health comorbidities are frequent in epilepsy. Consequently, psychotherapy is becoming increasingly important. To address the psychological needs of people with epilepsy (PwE) it is essential to understand the subjective experiences of seizures better. There is little research on how people report seizures, and which psychological representations they have. We conducted a thematic analysis based on 42 (micro-phenomenological) interviews with 15 participants on their experiences of seizures. In these interviews, we identified three categories of seizure descriptions: (1) phenomena related to the body and emotions; (2) the moments that are difficult to describe; and (3) the use of figurative language and metaphors. Paroxysmal physical and psychological sensations were often reported spontaneously by the participants. The moments that were difficult to describe were expressed, among other things, through the use of paradoxes or the report of a 'strange' feeling and led participants to use figurative language. As these metaphors can reveal important information about people's subjective experiences, they were analyzed in detail. We identified the three main types of metaphors that the participants used most frequently: (1) perception, (2) nature, and (3) battle. The theme of battle was most frequently used in different forms and was closely related to the metaphors from the fields of perception and nature, thus representing a key point in the personal experience of seizures. These findings can contribute to developing psychotherapeutic approaches for the treatment of seizure disorders.

Sleep-deprived electroencephalography, a forgotten investigation in psychiatry; a case series

OBJECTIVES

Many patients with psychiatric disorders may have epileptic disorders; however, clinical diagnosis without imaging investigation may result in misdiagnosis and thus resistance to treatment. We investigated electroencephalography (EEG) abnormalities in the patients with psychiatric disorders referred to us with treatment resistance.

METHODS

In this case series study, nine patients with mood and psychotic symptoms who were referred to us at Belmont Private Hospital, Australia, from August 2018 to July 2020, were evaluated.

RESULTS

Complete examination showed the presence of undiagnosed temporal lobe epilepsy. Notably, the seizure symptoms had been assumed as part of other psychiatric co-morbidities.

CONCLUSIONS

This study suggests the necessity of paying attention to the biological etiologies of mental illnesses in the initial assessments in psychiatric and neurological practice. Performing electroencephalogram and treating such patients with mood stabilizers, which have antiepileptic properties, can change the course of the mental illness decisively.

Correlation between FDG-PET brain hypometabolism and PTSD symptoms in temporal lobe epilepsy

The relationship between posttraumatic stress disorder (PTSD) and focal epilepsy is poorly understood. It has been hypothesized that there is a complex and reciprocal potential reinforcement of the symptoms of each condition. In this study, we investigated whether there are PTSD‐specific brain changes in temporal lobe epilepsy (TLE). Brain fluorodeoxyglucose positron emission tomography (PET) metabolism was compared between controls and two groups of TLE patients: one group of 15 patients fulfilling the criteria for a potential diagnosis of PTSD (TLE‐PTSD+), another group of 24 patients without a diagnosis of PTSD (TLE‐PTSD‐), and a group of 30 healthy control participants. We compared the differences in brain PET metabolism among these three groups, and we studied their correlations with interictal and peri‐ictal scales of PTSD symptoms. TLE‐PTSD+ patients showed more significant hypometabolism involving right temporal and right orbitofrontal cortex in comparison to TLE‐PTSD‐ patients and healthy subjects. Moreover, degree of reduced metabolism in these brain areas correlated with interictal and peri‐ictal PTSD questionnaire scores. PTSD in temporal epilepsy is associated with specific changes in neural networks, affecting limbic and paralimbic structures. This illustrates the close intertwining of epileptogenic and psychogenic processes in these patients.

Screening for epilepsy-specific anxiety symptoms: French validation of the EASI

OBJECTIVES

(1) To translate and validate the Epilepsy Anxiety Survey Instrument (EASI) in French people with epilepsy (PWE); (2) to further investigate the screening properties of each dimension of the EASI in terms of Diagnostic and Statistical Manual of Mental Disorders (DSM) anxiety disorders and of epilepsy-specific anxiety disorders, namely, anticipatory anxiety of seizures (AAS) and epileptic social phobia.

METHODS

Following back-translation, the French EASI was tested in PWE > 18 years using the Mini-International Neuropsychiatric Interview (MINI) as gold standard for DSM anxiety disorders. We added 3 original questions to explore epilepsy-specific anxiety symptoms. The Generalized Anxiety Disorders-7 (GAD-7), Neurological Disorders Depression Inventory for Epilepsy (NDDI-E), and Adverse Events Profile were performed for external validity. Receiver operator characteristics (ROC) were analyzed.

RESULTS

One hundred and forty nine native French speakers with epilepsy were included. Concerning DSM disorders, around 25% had GAD, 18% Agoraphobia, and <10% Social Phobia or Panic Disorder. Concerning possible epilepsy-specific anxiety disorder, 35% had AAS and 38% had epileptic social phobia. Bi-dimensional structure of the EASI was confirmed. Internal and external validity was satisfactory. ROC analysis showed AUC of 0.83 for detection of GAD and AUC 0.79 for other DSM anxiety disorders. ROC analysis of the 8-item French brEASI showed good performance for detection of GAD (AUC 0.83) and other DSM anxiety disorders (AUC 0.76) but not for epilepsy-specific anxiety symptoms (AUC 0.63). Conversely, dimension 2 of the French EASI (=10 items) allowed good detection of epilepsy-specific anxiety symptoms (AUC 0.78); cutoff > 4, sensitivity 82.4, specificity 66.7.

CONCLUSION

Epilepsy-specific anxiety symptoms were prevalent, in around 60%. The French version of the EASI showed robust performance. The French 8-item brEASI allows screening for all DSM anxiety disorders with superior performance than the GAD-7, but is less suited to screening for epilepsy-specific anxiety. We propose the "Epilepsy-Specific Anxiety" (ESA) 10-item screening instrument, based on dimension 2 of the EASI, as a complementary clinical and research tool.

Examining the role of astrogliosis and JNK signaling in post-traumatic epilepsy

OBJECTIVE

Post-traumatic epilepsy is a devastating complication of traumatic brain injury that has no targeted pharmacological therapy. Previous literature has explored the role of the c-Jun N-terminal kinase (JNK) pathway in epilepsy and the creation of epileptogenic foci by reactive astrogliosis; however, the relationship between reactive astrogliosis and the c-Jun N-terminal kinase signaling pathway in the development of post-traumatic epilepsy has not been thoroughly examined.

METHODS

Four experimental groups, consisting of c57/b16 male mice, were examined: (1) control, (2) traumatic brain injury of graded severity (mild, moderate, severe), (3) sub-convulsive kainic acid alone without traumatic brain injury (15 mg/kg i.p.), and (4) sub-convulsive kainic acid administered 72 h after moderate traumatic brain injury. Modified Racine scale from 1 to 72 h and total beam breaks at 72 h were used to assess seizure activity. Immunohistochemistry and western blot were utilized to examine astrogliosis (GFAP), microglia activation (IBA-1), and phosphorylated JNK in prefrontal cortex samples collected from the contracoup side at 72 h post-injury.

RESULTS

Astrogliosis, measured by GFAP, was increased after traumatic brain injury and increased commensurately based on the degree of injury. Mice with traumatic brain injury demonstrated a four-fold increase in phosphorylated JNK: p < 0.001. Sub-convulsive kainic acid administration did not increase seizure activity nor phosphorylation of JNK in mice without traumatic brain injury; however, sub-convulsive kainic acid administration in mice with moderate traumatic brain injury did increase phosphorylated JNK. Seizure activity was worse in mice, with traumatic brain injury, administered kainic acid than mice administered kainic acid.

CONCLUSIONS

Reactive astrocytes may have dysfunctional glutamate regulation causing an increase in phosphorylated JNK after kainic acid administration. Future studies exploring the effects of JNK inhibition on post-traumatic epilepsy are recommended.

Psychogenic non-epileptic seizures: Chronology of multidisciplinary team approach to diagnosis and management

While the diagnosis and management of psychogenic non-epileptic seizures (PNES) remain challenging, certain evidence-based guidelines exist, which can help to optimize patient care. A multidisciplinary team approach appears to have many benefits. Current recommendations exist for some aspects of diagnosis and management of PNES, including levels of diagnostic certainty as proposed by the International League Against Epilepsy's expert Task Force on PNES. Other aspects of clinical still care lack clear consensus, including use of suggestion techniques for recording PNES and optimal terminology, since the term "functional seizures" has recently been proposed as a possible term to replace "PNES". The present article aims to (1) review current recommendations and (2) discuss our own team's experience in managing patients with PNES. This is organized chronologically in terms of the roles of the neurologist, psychiatrist and psychologist, and discusses diagnostic issues, psychiatric assessment and treatment, and psychotherapeutic approaches.