Psychosocial sequelae of epilepsy: the role of associated cerebral pathology

Emotional and affective disturbances in patients with epilepsy

We sought to assess whether epilepsy is associated with a higher risk of emotional reactions to frustrating stimuli, aggressive behavior, apathy, and depression, and whether these psychiatric patterns are specific to the epileptic condition. The study population consisted of referral patients 17 years and older with idiopathic or cryptogenic epilepsy (i.e., epilepsy not caused by a detectable brain lesion) without significant cognitive dysfunction. A first control was selected for each patient among patients with insulin-dependent diabetes and a second among normal blood donors. Aggressiveness in response to stressful stimuli was assessed with the Picture Frustration Study (PFS). Depression was tested by the Beck Depression Inventory. The Aggressive Behavior Scale (assessing irritability and rumination) and the Apathy Scale were also used. Odds Ratios (ORs) with 95% Confidence Intervals (95% CI) were used as the risk measure. Statistical analysis included between-group comparisons. In patients with epilepsy, the test scores were correlated to the main demographic (age, sex, education, marital status, and occupation) and clinical features (seizure types, disease duration, seizure control, and treatments). The sample included 55 patients with epilepsy, 56 diabetics, and 59 normal individuals. Patients with epilepsy and the two control groups had similar PFS scores and similar aggressiveness. Scores were also similar for the Aggressive Behavior and Apathy Scales, with similar numbers of individuals with aggressive conduct and excess rumination. Patients with epilepsy had higher depression scores. Moderate to severe depression was present in 9 cases (diabetes, 2; blood donors, 1) (P=0.004). Relative to blood donors, the OR for moderate to severe depression (95% CI) was 2.1 (0.1-61.7) for diabetes and 11.3 (1.4-247.8) for epilepsy. No significant correlation was detectable between test scores and patient and disease characteristics.

Adjustment and coping in epilepsy

Our study investigated interrelationships between problems in psychosocial adjustment, coping and epilepsy variables. Establishing the cross-cultural applicability of the Washington Psychosocial Seizure Inventory (WPSI) was an additional objective. The WPSI, Ways of Coping Scale, Modified Version, as well as scales measuring depression and anxiety were administered to 310 outpatients with epilepsy. When the scores of patients with high Lie scores were eliminated, the WPSI profiles were found to be similar to former studies, with some score elevations in emotional adjustment and interpersonal adjustment. When relationships between adjustment variables and coping were modelled, coping was found to be a mediator between the effects of interpersonal and emotional adjustment and integration to the broader social context (vocational adjustment). Family background was found to be a significant predictor of the emotional well-being and interpersonal adjustment scores of the patients. Results support the central role of coping and emotional well-being and emphasize the importance of family factors in adjustment to epilepsy. Psychotherapy and psychological interventions could support coping with illness, primarily through elimination of negative family and social effects and treatment of emotional problems.

The coordinated psychosocial and neurologic care of children with seizures and their families

SUMMARY

As the medical and surgical management of epilepsy continues to advance, issues associated with the quality of life of patients and their families can be addressed. Whenever associated with other handicaps, such as learning disabilities, attentional or behavioral disorders, and problems in psychological adjustment, dual-diagnosis issues must be identified. To provide comprehensive care for children with epilepsy, a team approach to psychosocial assessment and treatment must be provided and coordinated with neurologic care. When the age-related needs in the life stage of the individual and family are identified, the best possible adaptation of the patient and his or her family can be supported.

Established antiepileptic drugs

Despite the recent entry into the market-place of a range of new pharmacological treatments for epilepsy, most patients still receive the standard antiepileptic drugs. This review considers the clinical place and practical use of these agents. Detailed consideration is given to carbamazepine, phenytoin, sodium valproate, phenobarbital and ethosuximide, with lesser emphasis on primidone, clobazam and clonazepam. Individualization of therapy, polypharmacy, refractory epilepsy, therapeutic drug monitoring, pregnancy, withdrawing treatment, epilepsy prophylaxis and referral to an epilepsy centre are also discussed. The paper concludes with a statement of 12 basic rules in prescribing established antiepileptic drugs.

The impact of posttraumatic seizures on 1-year neuropsychological and psychosocial outcome of head injury

This study examined the relationship of posttraumatic seizures and head injury severity to neuropsychological performance and psychosocial functioning in 210 adults who were prospectively followed and assessed 1 year after moderate to severe traumatic head injury. Eighteen percent (n = 38) of the patients experienced 1 or more late seizures (i.e., seizures occurring 8 or more days posttrauma) by the time of the 1-year followup. As expected, the head injured patients who experienced late posttraumatic seizures were those with the most severe head injuries, and they were significantly more impaired on the neuropsychological and psychosocial measures compared to those who remained seizure free. However, after the effects of head injury severity were controlled, there were no significant differences in neuropsychological and psychosocial outcome at 1 year as a function of having seizures. These findings suggest that worse outcomes in patients who develop posttraumatic seizures up to 1 year posttrauma largely reflect the effects of the brain injuries that cause seizures, rather than the effect of seizures.

Epilepsy

Diagnosis and management of the epilepsies are routinely performed by primary care physicians. In the United States, only 17% of patients with new-onset epilepsy are examined by neurologic specialists, and even fewer patients employ neurologists for their ongoing care. With the changes dictated by the evolving health care system in the United States, the responsibilities for the treatment of patients with epilepsies by primary care physicians will continue to increase. At the same time, there has been an explosion of new information about the diagnosis, evaluation, natural history, and neurobiologic aspects of epilepsy. New medical and surgical treatments are being introduced with a quickening pace. Finally, the concept that certain epilepsies may be progressive and that early identification and aggressive treatment represent one's best chance for establishing control for these patients has gained widespread confirmation from both clinical and animal model studies. The past standard of care is quickly ending. No longer should a patient or a physician accept only partial seizure control. This monograph attempts to lay the basis for improved understanding of epilepsy so that our patients will be seizure free without side effects and will be able to fully participate in our society.

Complex partial epileptic-like signs contribute differential sources of variance to low self-esteem and imaginings

64 university men and 55 university women displayed correlations (r = 0.40) between two psychometric inventories that have been employed to study subclinical complex partial epileptic-like signs in normal and traumatically brain-injured people. Although psychometric inferences of self-esteem and reports of childhood memories and imaginings were not significantly associated, both indicators of complex partial epileptic-like signs showed significantly positive associations with fantasy-prone behavior but significantly negative correlations with self-esteem. Subsequent analyses supported the vectorial hemisphericity model that elevated mesiobasal limbic activity may enhance imaginings while frequent intrusions into awareness of right-hemispheric indicators would be also associated with lower self-esteem. Lower self-esteem was correlated significantly with reported fears and phobias for the women but not for the men.

Reports of the experience of epilepsy in a rural South African village

It has become increasingly acknowledge that the social and psychological consequences of epilepsy may be more debilitating than the epileptic seizures themselves. This study, which formed part of an ongoing community health project which was carried out in the South African village of Mamre, was aimed at gaining an understanding of some of these psychosocial aspects. Sixteen respondents were as well as their families, had accepted the epilepsy and learnt to cope with it, although some respondents felt stigmatized by the epilepsy and made various attempts to conceal it from outsiders. Problems which were caused by epilepsy included the fear of going out unaccompanied, as well as forgetfulness and irritable mood. Few respondents had epilepsy which could be described as well-controlled, yet none admitted being dissatisfied with their treatment. Implications of the study included the need to assist the respondents and their families to better understand the management of epilepsy, so that every effort would be made to attain maximal seizure control.

Biologic factors as predictors of social outcome of epilepsy in intellectually normal children: a population-based study

We studied social outcome for all the normally intelligent children in our province with onset of epilepsy between 1977 and 1985 (excluding absence and "minor motor" seizures). After follow-up averaging 7 1/2 years, the 337 patients were 7 to 28 years of age. Outcome measures were age dependent. Of those old enough to be at risk, the percentage with each unfavorable outcome was as follows: school failure 34%, use of special educational resources 34%, mental health consultation 22%, psychotropic medication 5%, unemployment 20%, social isolation 27%, inadvertent pregnancy 12%, and criminal conviction 2%. In social isolation 27%, inadvertent pregnancy 12%, and criminal conviction 2%. In a multivariate model correcting for number of potential unfavorable outcomes (based on age at end of follow-up), many variables related to epilepsy, seizure control, and electroencephalographic findings were not associated with social outcome. Only two variables were associated with at least one unfavorable outcome--learning disorder (p < 0.001) and more than 21 seizures before treatment was begun (p < 0.03). The only variable with no unfavorable outcome was simple partial seizures (p < 0.003). Sensitivity and specificity of this model were 54% and 68%, respectively, indicating that social outcome for these children was often not related to biologic factors reflected by the medical details and clinical course of their disorder.

Formal thought disorder in pediatric complex partial seizure disorder

We compared the formal thought disorder ratings of 27 children with complex partial seizure disorder, 31 schizophrenic children and 58 normal children. The epileptic children with fullscale IQ scores below 100 had significantly more formal thought disorder than normal children with a similar IQ. The severity of their formal thought disorder was related to the age of seizure onset, seizure control and a diagnosis of schizophrenia spectrum disorder. The schizophrenic children had thought disorder irrespective of IQ scores. The cognitive correlates of their formal thought disorder scores differed from those of the epileptic children. Possible anatomical substrates of thought disorder in childhood complex partial seizure disorder and schizophrenia are discussed.

Drug interactions in epilepsy

The abolition of seizures using a single antiepileptic agent can be expected in more than 80% of patients, although not necessarily with the first drug tried. The remainder often receive polypharmacy, and current evidence suggests that perhaps only around 10% of these benefit significantly in terms of improved seizure control. Many more experience complicated drug interactions. Carbamazepine, phenytoin, phenobarbital, and primidone (metabolized in part to phenobarbital) all induce the synthesis of hepatic monooxygenase and conjugating enzymes. This will result in an acceleration in the metabolism of other lipid-soluble drugs with likely attenuation of their pharmacological effects. Valproate, on the other hand, is a minor enzyme inhibitor. Pharmacokinetic interactions are almost invariable when more than one antiepileptic drug is coprescribed. The extent and direction of interactions with combinations of these drugs are varied and unpredictable. Discontinuation of an enzyme inducer or inhibitor will influence the concentrations of the remaining drug(s). Pharmacodynamic interactions also cause problems in epileptic patients. A number of commonly prescribed psychoactive drugs, such as tricyclic antidepressants and neuroleptics, can worsen seizure control by reducing the convulsion threshold. In addition, there seems little doubt that ethanol abuse and withdrawal can precipitate seizures in susceptible patients. Antiepileptic polypharmacy is more likely to impair cognitive function than the same drugs used singly. In addition, the more antiepileptic drugs received by a patient in the first trimester of pregnancy, the higher the risk of teratogenesis in the exposed infant. Drug interactions prolong and complicate the process of new drug assessment, particularly when introduced in treated patients with refractory epilepsy. The candidate antiepileptic drug may alter the concentration of concomitant therapy, or its own breakdown may be influenced by coprescribed enzyme inducers or inhibitors. Even if the new drug is excreted unchanged by the kidney, unexpected interactions can be uncovered. Pharmacodynamic interactions need not always be detrimental. Currently, there is no rational approach to the treatment of intractable epilepsy. As more new drugs with single mechanisms of action become available, the potential exists for combining these synergistically. This approach may revolutionize the pharmacological management of the epileptic patient in the 21st century.

Knowledge about epilepsy among teachers and epileptic patients

223 epileptics patients and their families and 136 teachers from public and private schools were submitted to similar questionnaires related to inheritance, transmission, cure, complication rates, care during seizures, need for information on the disease, habits, comparison with other diseases and to the educational and social performance of epileptics. Cure and complication rates accounted for the main differences between those populations. Epileptics could recognize a bigger number of complications but still expected to be cured from the disease. The majority of teachers and patients have never been informed about epilepsy and this finding was related to the big number of equivocal answers obtained from them. Put together, the data showed that social and educational performance of epileptic patients could be disturbed by medical and social parameters. Some of them could be improved by an educational program towards these aspects of epilepsy.

An objective method for the assessment of psychosocial problems in adolescents with epilepsy

Psychosocial problems in adolescents with epilepsy have been of concern for many years, but have been difficult to assess. This article presents the multicenter development of the Adolescent Psychosocial Seizure Inventory (APSI), an empirically based self-report test patterned after the Washington Psychosocial Seizure Inventory, which is used to evaluate psychosocial problems in adults. After pilot work, 120 adolescents with epilepsy from five centers in North America took the APSI and were interviewed by professionals with respect to adequacy of adjustment in eight psychosocial areas. At least one parent or guardian was also interviewed. Interrater reliability of professional ratings in each area was established. Using an item-by-item, empirically based technique, eight psychosocial scales were developed as well as three validity scales. Reliability of the scales was established by both internal consistency and test-retest procedures. Results for each adolescent are presented in profile form. These results give a visual display of the types and extent of problems that likely would be identified in a detailed professional assessment. It is anticipated that the APSI will be of value in a variety of treatment and research contexts.

Cognitive function in adult epileptic patients established on anticonvulsant monotherapy

A battery of psychometric tests was administered to 110 patients with epilepsy and to 24 non-epileptic controls. Eighty-four patients had been established on treatment with a single anticonvulsant drug (35 carbamazepine (CBZ), 30 sodium valproate (VPA), 19 phenytoin (PHT)) at unaltered dosage for the previous 3 months. The remaining 26 patients were untreated at the time of study. No individual test discriminated between the groups. Tests were converted to standard scores and summated to give overall psychomotor, memory and side-effect assessments. There were no important differences between the performances of untreated epileptic patients and non-epileptic controls. The CBZ-treated patients had poorer psychomotor scores than both control groups and the VPA-treated patients (all P less than 0.05). The PHT patients scored less well on the composite memory scale than did VPA patients and non-epileptic controls (both P less than 0.05). There were no significant differences in subjective side-effects among the groups. This study demonstrated that anticonvulsant monotherapy has little effect on overall cognitive function in patients tolerating treatment. Psychomotor performance appeared to be selectively influenced by CBZ and memory impaired by PHT. VPA may be the drug to chose when cognitive function is an important consideration. Different cognitive modalities can be affected by different first-line anticonvulsants and this should be taken into account when choosing the most appropriate drug for an individual patient.

Concentration-effect relationships with carbamazepine and its epoxide on psychomotor and cognitive function in epileptic patients

A battery of psychometric tests was administered to 85 patients with epilepsy, of whom 26 were untreated, 40 received carbamazepine monotherapy and 19 took carbamazepine with another anticonvulsant. Carbamazepine alone had little effect on performance, but carbamazepine polypharmacy produced significant impairment. Increasing concentrations of carbamazepine (four tests) and its active metabolite, carbamazepine 10,11 epoxide (seven tests), correlated with decreasing performance in the monotherapy patients.

Socioeconomic accompaniments of severe epilepsy

Limited quantitative research has been undertaken on the social accompaniments of severe epilepsy. In this study we present new data from 92 patients with uncontrolled seizures necessitating admission to a special assessment unit in the United Kingdom. Comprehensive information on the medical, educational, and social history of each subject was obtained; moreover, they completed the Social Problems Questionnaire, which examines the respondent's level of satisfaction with various aspects of living including employment, finances, housing, etc. Thirty-nine percent of the sample reported moderate or severe dissatisfaction in four problem areas. The most frequently reported problems were with social contacts (73%) and employment (71%). The significance of these findings is discussed and some remedial strategies outlined.

Epilepsy

"Epilepsy" describes a heterogenous group of disorders bound together by their tendency to produce seizures. Recent advances in the basic neurosciences provide new insights into the pathophysiology and treatment of seizures. In the last decade, revisions of the classification schemata have led to improvements in the recognition of seizure types and of different epilepsies and epileptic syndromes. The clinical utility of these definitions is apparent in diagnosis, therapy, prognostication, and genetic counseling. A plan for the diagnostic evaluation of patients with epilepsy is presented. The therapeutic options for seizure treatment are reviewed including the withdrawal of anticonvulsants. Patients who should probably not be treated with anticonvulsants are identified. Psychological and life-style issues in the management of seizure patients are considered. The concept of adequate control is discussed. Surgical management, an increasingly employed therapeutic modality, is described.