The Bear Fedio Inventory: Twenty years on

Personality disorders in temporal lobe epilepsy: What do they signify?

OBJECTIVES

To estimate the prevalence of personality disorders in patients with temporal lobe epilepsy (TLE) with mesial temporal sclerosis (MTS) and compare it with general population and analyze their implications on treatment outcome.

MATERIALS AND METHODS

TLE was diagnosed based on clinical history, MRI, and Video EEG data. IPDE-ICD10 screening questionnaire was applied to investigate personality disorder in 120 subjects, 60 cases, and 60 normal controls. Bear-Fedio inventory (BFI) was used to study different behavior traits in patients with TLE and controls.

RESULTS

Prevalence of personality disorders was higher (71.7% in cases versus 38.3% in controls) in patients with TLE compared to controls (P < .001). Some personality traits like schizoid (P = .002), dissocial (P = .001), impulsive (P = .003), anankastic (P < .001), anxious (P < .001), and dependent (P < .001) personalities were found to have high prevalence in TLE. Personality disorder was higher among those cases who had been tried on more than two antiepileptic drugs (AEDs) (P = .033) and in those with duration of illness more than 10 years (P = .026). Cases also showed significantly higher score in BFI for all behavioral traits except for aggression. No significant difference of BFI score was seen based on laterality of epileptic focus, gender, duration of illness, or number of AEDs tried.

CONCLUSION

There is a significantly higher prevalence of personality disorders in patients with TLE. Specific interventions for these disorders should be considered at the earliest pari passu with AEDs and surgery.

Clinical and sociodemographic variables associated with interictal dysphoric disorder and interictal personality in patients with drug-resistant temporal lobe epilepsy: A controlled study

Psychiatric disorders (PD) have an elevated prevalence and an important negative impact on patients with epilepsy (PWE) since they are associated with lower quality of life and clinical refractoriness. However, it is also necessary to identify behavioral conditions possibly associated with epilepsy that are not part of the standard psychiatric classifications, such as Interictal Dysphoric Disorder (IDD) and Interictal Personality (IP). The frequency of IDD and IP in patients with drug-resistant temporal lobe epilepsy and mesial temporal sclerosis (TLE-MTS) was assessed. The Brazilian versions of the Neurobehavioral Inventory (NBI) and Interictal Dysphoric Disorder Inventory (IDDI) were applied to patients and to a control group. Psychiatric standard assessment was conducted through the Diagnostic and Statistical Manual for Psychiatric Disorders - 5th edition (DSM-5). The value of p considered significant was <0.05. Ninety-five patients (51 women; 53.6%) and 50 controls (29 women; 58.0%) were assessed. Axis I PD were observed in 41 patients (43.1%). Interictal Dysphoric Disorder was observed in 18 patients (18.4%) and IP in 36 (37.9%). Interictal Dysphoric Disorder was associated with left-sided MTS (OR=3.22; p=0.008), previous psychiatric treatment (OR=4.29; p=0.007), and more than one AED used (OR=2.73; p=0.02) while presence of bilateral MTS (OR=3.27; p=0.008), longer disease duration (OR=3.39; p=0.006), and presence of Major Depressive Disorder (OR=4.73; p=0.004) were associated with IP. In the present study, there was a high prevalence of IDD and IP in patients with drug-resistant TLE-MTS; studies should be conducted to identify the presence of behavioral conditions that are not present in the conventional psychiatric classifications.

Exploring psychiatric comorbidities and their effects on quality of life in patients with temporal lobe epilepsy and juvenile myoclonic epilepsy

AIM

The relation of epilepsy with psychiatric disorders is of great interest to researchers due to its behavioral, social, and cognitive outcomes. In this study, we explored psychiatric comorbidity and its effects on quality of life (QOL) in patients with mesial temporal lobe epilepsy (MTLE) and juvenile myoclonic epilepsy (JME).

METHODS

Thirty patients with MTLE, 30 patients with JME, and 30 healthy controls underwent the Structured Clinical Interview for DSM-IV (SCID-I) to diagnose psychiatric disorders. None of the subjects had previously undergone psychiatric examination. The Quality of Life in Epilepsy Inventory-89 (QOLIE-89) was used to assess QOL. We compared psychiatric comorbidity among groups and evaluated its effects on QOL.

RESULTS

We detected comorbid psychiatric disorders in 37% of patients with JME and in 57% of patients with MTLE. Comorbid psychiatric disorders were less frequent in healthy controls compared to the patient groups (P = 0.029). Comparing demographic and clinical features of patients with JME and MTLE and their mean QOL scores, there was no statistical difference. Furthermore, we compared QOLIE scores between patients with and without psychiatric comorbidity. JME patients with mood disorders had lower scores on the Attention/Concentration subscale (P = 0.013). MTLE patients with a psychotic disorder had lower scores on the Social Isolation, Energy, and Fatigue subscales (P = 0.045). Patients with somatoform disorders had higher Pain scores (P = 0.04).

CONCLUSION

Our study suggests that comorbid psychiatric disorders negatively affect patients' QOL regardless of seizure syndrome. Comorbid psychiatric conditions should be determined to increase QOL in patients with epilepsy.

Religious convictions in patients with epilepsy-associated affective disorders: a controlled study from a psychiatric acute department

Patients with epilepsy often have different mood symptoms and behavioral trait characteristics compared to the non-epileptic population. In the present prospective study, we aimed to assess differences in behavioral trait characteristics between acutely admitted, psychiatric in-patients with epilepsy-associated depressive symptoms and gender/age-matched patients with major depression. Patients with epilepsy-associated depression had significantly higher scores for "religious convictions," "philosophical and intellectual interests" and "sense of personal destiny." These behavioral trait characteristics at admission or in clinical history should alert the psychiatrist and lead to closer examination for a possible convulsive disorder.

Long-term treatment and poor management of psychiatric manifestations in mesial temporal sclerosis leading to suicidality in a young male

Psychiatric disorders including anxiety, psychosis, and aggressive behaviors are frequently diagnosed in patients with epilepsy. In this communication, we report a patients with mesial temporal lobe sclerosis with interictal affective-somatoform (dysphoric) disorders who was never treated for psychiatric manifestations, and who deliberately took a massive dose of phenytoin and phenobarbitone with a motive of suicide, resulting in severe combined toxicity. Such unfortunate incidences may be prevented, and quality of life can be improved with early diagnosis, through the selection of the right antiepileptic drugs, reasonable psychiatric consultation, and appropriate biological and psychological treatments.

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.

Juvenile myoclonic epilepsy: psychiatric comorbidity and impact on outcome

Juvenile myoclonic epilepsy (JME) is a well-defined age-related idiopathic epilepsy syndrome. Past studies have emphasized the difficulties in the treatment of patients with JME, which have been attributed to some specific psychiatric, psychological, and psychosocial characteristics. These aspects have aroused a significant amount of interest in the last two decades. In this article, the available studies that investigated the prevalence of psychiatric disorders (PDs) in JME and its impact on seizure outcome were reviewed in order to provide an update to clinicians about these two important aspects associated with this common epilepsy syndrome. The review disclosed a high prevalence of PDs in patients with JME, particularly mood, anxiety, and personality disorders. In addition, most recent studies have also observed that overall prevalence of PDs in JME has not shown statistically significant differences when compared with TLE, an epilepsy syndrome where the psychiatric aspects are most frequently studied. Taken together, data regarding the prevalence of PDs and their possible consequences on seizure outcome on JME indicate that special attention should be directed to psychological disturbances and psychiatric symptoms in this epilepsy syndrome. The early recognition and treatment of psychiatric symptoms, as well as psychological disturbances and psychosocial difficulties, should be considered fundamental to JME prognosis.

Psychiatric comorbidity in patients with two prototypes of focal versus generalized epilepsy syndromes

The frequency of psychiatric disorders (PD) in a homogeneous series of patients with temporal lobe epilepsy with mesial temporal sclerosis (TLE-MTS) compared to patients with juvenile myoclonic epilepsy (JME) was evaluated, aiming to determine the frequency of PD and possible differences in psychiatric diagnoses between these two epileptic syndromes. Data from 248 patients with refractory TLE-MTS and from 124 JME patients were reviewed and compared. There was a high prevalence of PD in both groups of epilepsy patients, present in 100 TLE-MTS (41%) and in 58 JME patients (46.7%). Mood (23.7%), anxiety (13.7%) and psychotic (11.6%) disorders were the most frequent diagnoses in TLE-MTS group, while mood and anxiety disorders (25% and 21%, respectively) were the most common PD among JME. Psychoses were significantly associated with TLE-MTS (p=0.01). These observations are concordant with our previous study, reforcing the existence of a possible anatomic correlation of PD and brain structures involved in both epilepsy syndromes.

Adaptação transcultural do inventário neurocomportamental (NBI) para o Brasil

OBJETIVO: Realizar a adaptação transcultural de instrumento para avaliação das alterações comportamentais tipicamente descritas em portadores de epilepsia do lobo temporal (ELT), o Inventário Neuro-Comportamental (NBI) para a população brasileira. MÉTODOS: Inicialmente, foi feita a tradução do instrumento original para o português. Esta versão foi revisada e retrotraduzida para o inglês. A seguir, a versão retrotraduzida foi comparada à versão original em inglês, sendo corrigidas as divergências no texto em português. Em um segundo momento, 15 pacientes do Ambulatório de Epilepsia do Hospital das Clínicas da UFMG portadores de ELT responderam ao inventário. À aplicação do questionário, eventuais dificuldades e os itens mal compreendidos foram analisados pelos autores. RESULTADOS: Na versão final para o português, os itens 11, 14, 17, 61 e 75 foram modificados. Sete pacientes (46,7%) eram do sexo feminino, com idade entre 26 e 65 anos. A maioria dos pacientes (93,3%) apresentou uma pontuação total elevada. Os domínios mais comumente alterados foram hiperreligiosidade, detalhismo e crença na predestinação pessoal (73,3% dos pacientes em cada um deles). CONCLUSÃO: A versão em português do NBI pode ser um instrumento útil para avaliar alterações comportamentais na ELT aplicada ao contexto clínico dos pacientes brasileiros.

Transtornos psiquiátricos na epilepsia: uma proposta de classificação elaborada pela comissão de neuropsiquiatria da ILAE

INTRODUÇÃO: Um dos aspectos mais importantes da epileptologia é o da sua relação com as comorbidades psiquiátricas. Transtornos psiquiátricos (TP) são associados a praticamente todas as síndromes epilépticas e contribuem para uma maior dificuldade no manejo desses pacientes. OBJETIVO: O presente trabalho tem como objetivo fazer uma revisão das classificações dos TP na epilepsia e destacar a proposta elaborada pela Comissão de Neuropsiquiatria da ILAE. CONCLUSÃO: A proposta de classificação elaborada pela ILAE procurou diferenciar os TP que ocorrem em comorbidade daqueles que refletem atividade epileptiforme ou que ocorrem especificamente na epilepsia, sendo baseada em aspectos clínicos e descritivos mais do que em etiologias. Apresenta ainda critérios bastante claros e operacionais, constituindo-se de grande utilidade para futuros estudos dos quadros psiquiátricos na epilepsia.

Psychiatric comorbidity in epilepsy: a study comparing patients with mesial temporal sclerosis and juvenile myoclonic epilepsy

We evaluated the frequency of psychiatric disorders (PDs) in a homogenous series of patients with temporal lobe epilepsy with mesial temporal sclerosis (TLE-MTS), as compared with patients with juvenile myoclonic epilepsy (JME), aiming to determine possible differences in psychiatric diagnoses between these two epileptic syndromes. Data from 170 patients with refractory TLE-MTS and from 100 patients with JME were reviewed and compared. The prevalence of PDs was high in both groups of patients with epilepsy: PDs were present in 85 patients with TLE-MTS (50%) and 49 patients with JME (49%). Among the TLE-MTS group, mood (25.8%), psychotic (15.8%), and anxiety (14.1%) disorders were the most frequent diagnoses, whereas anxiety and mood disorders (23 and 19%, respectively) were the most common among patients with JME. Psychoses were significantly associated with MTS (P<0.01) and anxiety disorders with JME (P<0.05). These findings suggest the existence of an anatomic correlation between PDs and brain structures involved in both epilepsy syndromes.

Prevalence of psychiatric disorders in patients with mesial temporal sclerosis

OBJECTIVE: Behavioral changes in patients with epilepsy can range from depression, anxiety to psychosis and personality traits. We evaluated the frequency of psychiatric disorders (PD) in a homogenous series of patients with refractory temporal lobe epilepsy (TLE) related to mesial temporal sclerosis (MTS) aiming at determining the frequency of PD and possible correlations to clinical variables and to laterality of MTS. METHODS: Data from 106 refractory TLE patients were reviewed. Psychiatric evaluation was based on DSM-IV criteria. Statistical analysis was performed through the chi-square (chi²), Student's t test and Fisher's exact test. P value considered significant was < 0.05. RESULTS: PD were found in 65 patients (61.3%). Among them, mood disorders were the most frequent (32 patients; 30%), followed by interictal (15 patients; 14%) and postictal (10 patients; 9.4%) psychosis. Postictal and interictal psychosis were significantly associated with left side MTS (p < 0.05), while PD in general and mood disorders were not associated to any side. CONCLUSION: There was a high prevalence of PD in patients with refractory TLE associated to MTS. The most common were mood and psychotic disorders. Psychosis was significantly associated to left side. These findings are concordant with data in literature, confirming the existence of anatomic alterations, and also a possible left laterality effect in the mesial temporal lobe structures in patients with epileptic psychosis.

The Evaluation of Behavioral Disturbances in Epilepsy

The evaluation of behavioral disturbances in epilepsy is an area fraught with complexity. On the one hand, there are no instruments that have been developed specifically for the assessment of behavioral disturbances in epilepsy. On the other hand, the phenomenology and pathophysiology of behavioral disturbances in epilepsy are unique and defy conventional descriptions in the psychiatric literature. The vast majority of studies have used instruments that have not been validated for this purpose. Studies with a psychiatric orientation generally tend to employ unvalidated semistructured or structured tools except for the Structured Clinical Interview for DSM, which has been validated for epilepsy. Studies with a neurological orientation generally use screening questionnaires and interpret the results of these as diagnostic. Neither approach is valid and both generally fail to measure potential confounders, such as seizure frequency, seizure severity, temporality of seizure occurrence in relation to time of assessment, life events, disablement, quality of life, and other socioeconomic indicators. Furthermore, instruments are generally employed using cutoff scores that may not be valid for epilepsy populations; the emphasis is often on symptom severity rather than symptom multiplicity (or load), which may also have an impact on the patient's outcome. In addition, instruments that have a basis in psychiatric criteria as opposed to symptomatology have inherent pitfalls at the interface between epilepsy and behavior. These and other issues in evaluating behavioral disturbances in people with epilepsy are reviewed and some solutions for the future are proposed.

An investigation of religiosity and the Gastaut-Geschwind syndrome in patients with temporal lobe epilepsy

We examined the religious experiences of 28 patients with epilepsy and religiosity, 22 patients with epilepsy and no expressed interest in religion, and 30 volunteer regular churchgoers. We profiled the experiences of the first group, revealing more of their phenomenology, but also their bipolarity, and demonstrated that members of the religious group were significantly more likely to have had past episodes of postictal psychosis, and to have bilateral cerebral dysfunction. We added further data to support the validity of the Bear-Fedio Inventory, and noted that although the experiences of patients with epilepsy are different in content and intensity from the experiences of regular churchgoers, the patients with epilepsy and religiosity conform to those who William James referred to as having, with respect to religion, "an acute fever."