Interictal behaviour in hospitalised temporal lobe epileptics: relationship to idiopathic psychiatric syndromes

Verbosity with retelling: Narrative discourse production in temporal lobe epilepsy

To examine micro- and macrolinguistic underpinnings of circumstantiality in temporal lobe epilepsy (TLE), we examined the elicited narrative output of 15 individuals with TLE and 14 controls. To replicate and extend Field and colleagues' (2000) work, participants were asked to produce five immediately consecutive elicitations of an eight-frame cartoon "Cowboy Story" (Joanette et al., 1986). Following transcription and coding, detailed multi-level discourse analysis demonstrated a typical pattern of compression in controls. The narratives produced by individuals with TLE were less fluent, cohesive, and coherent across trials: producing fewer novel units and more repetitive and extraneous content. Significant group by trial interactions in sample length, spontaneous duration, and statements, were not explained by seizure burden, age, or lexical retrieval deficits. These findings suggest that they do not benefit from repeated engagement with a narrative in the same manner as controls. Disturbed social cognition and pragmatics in TLE might underpin communication inefficiencies.

Vague retellings of personal narratives in temporal lobe epilepsy

PURPOSE

Aside from deficits identified in single-word level retrieval, individuals with temporal lobe epilepsy (TLE) exhibit clinical oddities, such as circumstantiality in their language production. Circumstantiality refers to the use of language which is pedantic, repetitive, and overly detailed. This becomes particularly evident when elicitation tasks impose minimal structure, or when impersonal narratives are retold over consecutive occasions. Personal reminiscence is highly specific and localised in time, placing unique demands on cognitive-linguistic systems. It is hypothesised that the nature of this elicitation paradigm will produce a unique psycholinguistic phenotype in those with TLE. Among controls there is a compression of output for impersonal narratives, meaning that they use fewer words over less time and are more fluent. The opposite effect is observed when personal narratives are retold.

METHODS

To investigate the micro- and macrolinguistic processes underpinning personal discourse production in TLE, we examined the elicited language output of 15 surgically naïve individuals with TLE and 14 healthy controls. Participants were asked to recall and re-tell an autobiographical memory on four immediately consecutive occasions, representing an alternative unstructured elicitation. Following transcription and coding of output, a detailed multi-level discourse analysis of output volume, fluency, cohesion, and coherence was conducted.

RESULTS

As anticipated, a distinctly different pattern emerged in TLE when compared with controls who did not compress their output volume across repetitions but instead produced greater novelty, and a more coherent and refined account over time. Individuals with TLE consistently told a less distinct story across repetitions, with disturbances in fluency, cohesion, and coherence.

CONCLUSION

This reflects a reduced capacity to produce a coherent mental representation, in all likelihood related to the neurolinguistic demands of recalling and retelling specific personal events.

Superlative Artistic Abilities in a Patient With Post-traumatic Brain Injury

This case describes a patient who exhibits newfound superlative abilities in painting, music, philosophy, culinary, and performing arts after a traumatic brain injury (TBI) involving the frontal and temporal lobes. Such a dramatic change in de novo artistic behavior after brain injury is rare but has been reported in other patients with frontotemporal dementia, as well as other neurological diseases. Previous studies have shown that mild frontal cortical dysfunction likely plays a role in facilitating creative endeavors and that artistic circuitry is distributed throughout the brain. The neuronal reorganization which occurs after injuries enhances synapse formation and neural plasticity, which may contribute to the acceleration of artistic output after brain injury. This is likely an underdiagnosed phenomenon and a deeper understanding is required to allow clinicians to more effectively recognize and nurture newfound creativity in the setting of brain damage.

Personality traits in patients with refractory versus non-refractory epilepsy

Background

Epilepsy has significant effects on the behavior of most people who suffer it. In some cases, the seizure activity itself is manifested as a brief change in behavior that might appear unusual to the casual observer. Evidence also suggests that epilepsy can affect behavior when seizures are not occurring. Descriptions of inter-ictal behavior in people with epilepsy have a long and controversial history. The study aims to assess the personality disorders among epileptic patients and impact of the severity of epilepsy on personality traits. Methods: This study is conducted upon 90 patients presented at outpatient clinic of epilepsy in Assiut University Hospital diagnosed as having epilepsy versus 40 cross-matched healthy controls. Patient group were classified into two groups (refractory versus controlled groups). All patients and control were subjected to (1) detailed medical interview. (2) Assessment of intelligence using The Arabic Version of Wechsler Adult Intelligence Scale. (3) Conventional EEG study. (4) The Arabic Version of The Structured interview for the five-factor model of personality.

Results

A relationship was found between personality traits and the severity of epilepsy. When patients have more severe epilepsy, they often have a high seizure frequency, they use more antiepileptic medications. It is likely that in those patients the need for control is usually high (because seizures mean a loss of control). Regarding the five-factor model of personality which we used to assess the personality traits of our selected studied samples, we found that the five main domains of the scale which are neuroticism, extraversion, openness to experience, agreeableness and conscientiousness differ markedly between the two groups of our patients. We found neuroticism was markedly increased at the refractory epileptic patients than the controlled epileptic ones, while extraversion, openness to experience, agreeableness, and conscientiousness increased at the controlled epileptic patients than the refractory epileptic ones.

Conclusion

Patients with epilepsy have raised scores for several personality traits also those personality traits are different in patients with refractory and controlled epilepsy. Also, those personality traits are different compared with a control group from the general population.

Effects of Anterior Temporal Lobectomy Apart from the Relief of Seizures: A Study of 40 Patients

The effect of temporal lobectomy, apart from the relief of seizures, is described in 40 patients undergoing the operation and followed up for between 2 and 6 years. Changes in their intellectual performance and mental state are described, and the possible mechanisms of these changes are discussed.

Multidisciplinary assessment and treatment of self-injurious behavior in autism spectrum disorder and intellectual disability: integration of psychological and biological theory and approach

The objective of this review is to consider the psychological (largely behavioral) and biological [neurochemical, medical (including genetic), and pharmacological] theories and approaches that contribute to current thinking about the etiology and treatment of self-injurious behavior (SIB) in individuals with autism spectrum disorder and/or intellectual disability. Algorithms for the assessment and treatment of SIB in this context, respectively, from a multidisciplinary, integrative perspective are proposed and challenges and opportunities that exist in clinical and research settings are discussed.

A critical and descriptive approach to interictal behavior with the Neurobehavior Inventory (NBI)

PURPOSE

The purpose of this study was to test the psychometric properties of the Neurobehavior Inventory (NBI) in a group of temporal lobe epilepsy (TLE) patients from a tertiary care center, correlating its scores with the presence of psychiatric symptoms.

METHODS

Clinical and sociodemographic data from ninety-six TLE outpatients were collected, and a neuropsychiatric evaluation was performed with the following instruments: Mini-Mental State Examination (MMSE), structured psychiatric interview (MINI-PLUS), Neurobehavior Inventory (NBI), and Hamilton Depression Rating Scale (HAM-D).

RESULTS

Some traits evaluated by the NBI showed adequate internal consistency (mean inter-item correlation between 0.2 and 0.4) and were frequent, such as religiosity (74%) and repetitiveness (60.4%). Principal component analysis showed three factors, named here as emotions (Factor 1), hyposexuality (Factor 2), and unusual ideas (Factor 3). Depressive symptoms on HAM-D showed a strong association with emotions and hyposexuality factors. When patients with left TLE and right TLE were compared, the former exhibited more sadness (p=0.017), and the latter, a greater tendency toward sense of personal destiny (p=0.028).

CONCLUSION

Depression influences NBI scoring, mainly emotionality and hyposexuality traits. Neurobehavior Inventory subscales can be better interpreted with an appropriate evaluation of comorbid mood and anxiety disorders. Compromise in left temporal mesial structures is associated with increased tendency toward sad affect, whereas right temporal pathology is associated with increased beliefs in personal destiny.

Epilepsy, mental health disorder, or both?

Temporal lobe epilepsy (TLE), a subset of the seizure disorder family, represents a complex neuropsychiatric illness, where the neurological presentation may be complemented by varying severity of affective, behavioral, psychotic, or personality abnormalities, which, in turn, may not only lead to misdiagnosis, but also affect the management. This paper outlines a spectrum of mental health presentations, including psychosis, mood, anxiety, panic, and dissociative states, associated with epilepsy that make the correct diagnosis a challenge.

Misdiagnosis of epileptic seizures as manifestations of psychiatric illnesses

BACKGROUND

Epileptic seizures may be misdiagnosed if they manifest as psychiatric symptoms or seizures occur in patients with known psychiatric illness.

METHODS

We present clinical profiles of six patients with epilepsy (three male, mean age 39 ± 12 years) that presented with prominent psychiatric symptoms.

RESULTS

Two patients had pre-existing psychiatric illnesses. Three patients were initially diagnosed with panic attacks, two with psychosis, and one with schizophrenia. Five patients had temporal lobe epilepsy (TLE) while the sixth patient was subsequently found to have absence status epilepticus (SE). Cranial computed tomogram (CT) including contrast study was unremarkable in five patients and showed post-traumatic changes in one patient. Cranial magnetic resonance imaging (MRI) revealed dysembryoplastic neuroepithelial tumour (DNET) in one patient, cavernous hemangioma in one, and post-traumatic changes plus bilateral mesial temporal sclerosis in another patient but it was normal in two TLE patients. Routine electroencephalography (EEG) revealed absence SE in one patient but it was non-diagnostic in the TLE patients. Video-EEG telemetry in the epilepsy monitoring unit (EMU) was necessary to establish the diagnosis in four TLE patients. None of the patients responded to medications aimed at treating psychiatric symptoms alone. Two patients required surgery while the other four required treatment with anti-epileptic drugs. All the patients had favorable response to the treatment of their epilepsy.

CONCLUSIONS

This case series illustrates that epileptic patients may experience non-convulsive seizures that might be mistaken as primary psychiatric illnesses. In this subset of patients, evaluation by an epileptologist, MRI of the brain, and/or video-EEG telemetry in an EMU was necessary to confirm the diagnosis of epilepsy if routine EEGs and cranial CT are normal.

Norman Geschwind's contribution to the understanding of behavioral changes in temporal lobe epilepsy: the February 1974 lecture

Norman Geschwind catalyzed academic interest in the study of interictal behavioral changes in temporal lobe epilepsy. His contributions to this area comprise a series of 11 articles, chapters, editorials, and commentaries published between 1973 and 1984. This article summarizes, both chronologically and by behavioral topic, Geschwind's contributions and opinions on behavioral changes in temporal lobe epilepsy. A previously unpublished lecture (see article in this issue), "Personality Change in Temporal Lobe Epilepsy," from his course at Harvard Medical School on The Neurology of Behavior (1974), is also quoted to further illustrate his views on specific features of this syndrome. Notably, many of Geschwind's observations and formulations regarding this topic were highly developed in 1974, reflecting his long-standing interest in behavioral changes in epilepsy. Geschwind and his collaborators viewed temporal lobe epilepsy as an important model of behavioral change resulting from a stimulating lesion in the limbic system. This neurobiology accounted for the overarching increased interictal emotionality that underlay the increased religious interests, hypergraphia, increased aggression, increased moral and philosophical concerns, viscosity, and seriousness (lack of humor). Hyposexuality was the exception, although it was consistent with a discharging lesion altering this emotion-driven behavior. Geschwind provided a series of arguments to support the existence of this limbic syndrome and explain why alternative views (e.g., destructive lesion, psychological factors) and arguments against the syndrome's existence are inconsistent with the data.

Is our brain hardwired to produce God, or is our brain hardwired to perceive God? A systematic review on the role of the brain in mediating religious experience

To figure out whether the main empirical question "Is our brain hardwired to believe in and produce God, or is our brain hardwired to perceive and experience God?" is answered, this paper presents systematic critical review of the positions, arguments and controversies of each side of the neuroscientific-theological debate and puts forward an integral view where the human is seen as a psycho-somatic entity consisting of the multiple levels and dimensions of human existence (physical, biological, psychological, and spiritual reality), allowing consciousness/mind/spirit and brain/body/matter to be seen as different sides of the same phenomenon, neither reducible to each other. The emergence of a form of causation distinctive from physics where mental/conscious agency (a) is neither identical with nor reducible to brain processes and (b) does exert "downward" causal influence on brain plasticity and the various levels of brain functioning is discussed. This manuscript also discusses the role of cognitive processes in religious experience and outlines what can neuroscience offer for study of religious experience and what is the significance of this study for neuroscience, clinicians, theology and philosophy. A methodological shift from "explanation" to "description" of religious experience is suggested. This paper contributes to the ongoing discussion between theologians, cognitive psychologists and neuroscientists.

Anxious bliss: a case study of dissociation in a Mexican nun

This is a case study of Celeste, postulant in a Roman Catholic convent in Mexico who experienced frequent episodes of leaving her body to commune with God. During these experiences, Celeste felt immersed in an ;incredibly beautiful profound silence' where ;time and space were broken.' But as much as Celeste craved these experiences, they also alarmed her; she was acutely aware that they might be indicative of psychological or neurological dysfunction. This article chronicles Celeste's struggles to make sense of her experiences in light of competing explanatory models. Her ultimate resolution suggests intriguing new directions for transcultural psychiatric research.

[The development of the personality in childhood epilepsy with complex-partial seizures]

The study presented addresses the association between severity and course of childhood epilepsy with complex-partial seizures and subsequent personality development. Participants in the study were 84 patients first seen when they were 8 years on average. A follow-up examination was conducted about 13 years thereafter. At the first examination about half of the patients showed a psychiatric disorder, another quarter showed developmental delays and 35% were mentally retarded. It could be demonstrated that a high frequency of complex-partial seizures was related to depressive symptoms. However, additional generalized seizures did not further contribute to the severity of psychiatric problems. Patients who continued to show seizures reported less life satisfaction, a more passive attitude and higher emotional instability at follow-up in comparison to patients with a complete remission of epilepsy.

The role of the extrapersonal brain systems in religious activity

The neuropsychology of religious activity in normal and selected clinical populations is reviewed. Religious activity includes beliefs, experiences, and practice. Neuropsychological and functional imaging findings, many of which have derived from studies of experienced meditators, point to a ventral cortical axis for religious behavior, involving primarily the ventromedial temporal and frontal regions. Neuropharmacological studies generally point to dopaminergic activation as the leading neurochemical feature associated with religious activity. The ventral dopaminergic pathways involved in religious behavior most closely align with the action-extrapersonal system in the model of 3-D perceptual-motor interactions proposed by . These pathways are biased toward distant (especially upper) space and also mediate related extrapersonally dominated brain functions such as dreaming and hallucinations. Hyperreligiosity is a major feature of mania, obsessive-compulsive disorder, schizophrenia, temporal-lobe epilepsy and related disorders, in which the ventromedial dopaminergic systems are highly activated and exaggerated attentional or goal-directed behavior toward extrapersonal space occurs. The evolution of religion is linked to an expansion of dopaminergic systems in humans, brought about by changes in diet and other physiological influences.

Partial seizure-like symptoms in borderline personality disorder

The clinical presentation of borderline personality disorder (BPD) bears a striking resemblance to the behavioral alterations associated with temporal lobe epilepsy. Using the Limbic System Checklist-33, we found that BPD subjects reported more symptoms associated with partial seizures than did control subjects. BPD patients also exhibited deficits on immediate and delayed recall of the Rey-Osterrieth Complex Figure and produced distorted drawings of the Rey Figure. Their degree of impairment correlated with their report of temporolimbic symptoms. Results are consistent with the proposal that temporolimbic dysfunction underlies the behavioral dyscontrol and affective dysregulation present in BPD.

Long-term amygdala kindling in rats as a model for the study of interictal emotionality in temporal lobe epilepsy

Temporal lobe epileptics often experience profound interictal (i.e. between seizure) emotional disturbances, such as fear, anxiety, and depression. Although the presence of this interictal emotionality has been well documented, little progress has been made in identifying its precise nature and cause because it is not amenable to experimental analysis in clinical populations. Accordingly, there is much to gain by studying the fundamental nature and neural basis of interictal emotionality using animal models. Kindling is a widely studied animal model of temporal lobe epilepsy in which daily electrical stimulation of certain brain regions results in the gradual progression and intensification of limbic motor seizures. Several investigators have found that partial and short-term kindling produce robust changes in emotional behavior in both cats and rats. Recently, our laboratory has developed a new model to study interictal emotionality using long-term kindling in rats. These long-term kindled rats display profound changes in fearful and defensive behavior which last for at least two months after the final stimulation. We are now beginning to use this model to study the neural mechanisms underlying the development and expression of interictal emotionality.

Interictal discourse production in temporal lobe epilepsy

Discourse production was investigated in 16 patients with left-temporal-lobe epilepsy (LTLE) and 17 neurologically normal relatives. Narrative was elicited with the Joanette and Goulet (1989) eight frame "Cowboy" cartoon on three immediately consecutive occasions. Variables of interest were fluency (words/s), speaking time, and word count. While controls produced increasingly concise forms of the story over repetitions, the TLE group became more verbose. Fluency did not not differentiate the groups. These findings suggest that LTLE is associated with macrolinguistic disturbances. The role of capacity limitations and motivational factors in TLE discourse production is discussed.

[Interictal personality syndrome in non-dominant temporal lobe epilepsy: case report]

The syndrome of interictal personality in non-dominant temporal lobe epilepsy consists of hyposexuality, hyperreligiosity, humorlessness and hypergraphia. Its notification, in 1974, was followed by an extensive search for these traits in broad epileptic populations. Nevertheless, these statistical studies failed to match this syndrome in general temporal lobe epileptics, and its existence became then target of doubt. We report the case of a 35 year-old man presenting partial complex epilepsy, whose singularity lies in his sophisticated drawing abilities. The large amount of buildings and houses he paints expresses his hypergraphia. He also presents hyposexuality and hyperreligiosity. MRI shows right mesial temporal sclerosis. Temporal hyperconnection, caused by a basal temporal irritative focus, is the most probable pathophysiological mechanism. Epileptic fits can be controlled in the majority of cases. However, behavioural symptoms usually do not respond to pharmacological approach or psychotherapy.

Regional cerebral blood flow in alcohol-induced violence: a case study

A case is presented of a 20-year-old man who became violent on many occasions after ingesting alcohol. On one occasion he committed an armed robbery. Two brain SPECT studies were performed: one when he was alcohol free, and one after he ingested alcohol in the same pattern as the night of the crime. The "alcohol free" study revealed marked hyperactivity in the cingulate gyrus, right and left lateral frontal lobes, right and left lateral parietal lobes and the right lateral temporal lobe. The "alcohol intoxication" study showed an overall dampening effect on the hyperactive areas of the brain, with only the anterior cingulate gyrus showing excessive activity. In addition, the right and left prefrontal cortex became hypoperfused, decreasing impulse control and judgment, as did the left and right temporal lobes, increasing the likelihood for aggression. This study suggests that this man may have been "self-medicating" an overactive brain, but in the process induced a state that increased the likelihood for aggressive behavior. This case study suggests the need for further research in the area of alcohol-induced violence and the potential usefulness of SPECT imaging, although no conclusions can be drawn from one case.

Visualizing the firestorms in the brain: an inside look at the clinical and physiological connections between drugs and violence using brain SPECT imaging

The connection between drugs and violence has been well documented. Understanding the intricacies of this connection is essential to finding effective interventions. Much has been written about the psychosocial causes of these problems, but there have been few studies exploring the biophysiological interface between drug effects, violent behavior and brain metabolism. Over the past eight years, The Amen Clinic has been extensively involved in the clinical use of brain SPECT imaging to evaluate complicated neuropsychiatric problems, especially related to the issues of both violence and substance abuse. From this work several clinical patterns, as well as brain SPECT imaging patterns, have been recognized that may help further our understanding of these problems. In this article, following a brief review of the literature on drugs, violence and the brain, five clinical examples are explored; the authors show how these support the clinical utility of incorporating SPECT imaging into psychiatric assessment of drug abuse and violence. Finally, a model is proposed to help explain the complex interaction between the brain, violence and drug abuse.

A clinical study of hypergraphia in epilepsy

Fifteen patients with epilepsy and hypergraphia were compared with 32 patients with epilepsy but without hypergraphia. The number of previous psychiatric episodes, the number of Washington Psychosocial Seizure Inventory (WPSI) items indicating emotional maladjustment, and the number of CT scan abnormalities were significantly greater in the hypergraphic patients than in the non-hypergraphic patients. Cognitive performance, EEG laterality and the scores of WPSI items related to the psychological stress of seizures did not differ significantly between the two groups. Hypergraphia reflects changes in emotional responsiveness secondary to organic temporal lobe lesions.

Neurobiological models of obsessive-compulsive disorder

The authors review current neurobiological models of obsessive-compulsive disorder (OCD). The rationale for anatomically based models is outlined and selected brain regions of interest are discussed. The authors conclude that there is abundant evidence to implicate multiple brain regions as sites of abnormality in OCD. A review of neuropharmacological concepts related to the serotonergic (5-HT) hypothesis of OCD is also presented. The authors conclude that anti-obsessional agents may well have therapeutic effects via the 5-HT system, yet there is little unequivocal evidence to suggest an underlying abnormality in the 5-HT system. A comprehensive neurobiological model of OCD must acknowledge the interrelationship between multiple transmitter systems and integrate anatomical with neuropharmacological concepts.

Facilitation of infantile spasms by partial seizures

We report 16 patients with infantile spasms in whom onset of the clusters of spasms appeared to be triggered by close temporal association with partial seizures. Common features included the presence of focal cerebral lesions in 12 infants (3 were classifiable as cryptogenic); all had partial seizures with EEG localization, clusters of bilateral spasms always preceded by partial seizures, and response to adrenocorticotropic hormone (ACTH) and traditional antiepileptic drugs (AEDs) generally was poor. Three had complete agenesis of the corpus callosum, which argues against interhemispheric callosal spread of focal discharges resulting in the generalized spasms. Surgical cortical resections were performed in 6 of the infants, with good outcomes. This group of patients supports a model in which the spasms, although probably generated at a subcortical level, are facilitated or possibly induced by focal discharges from cortical pathology.

Viscosity and social cohesion in temporal lobe epilepsy

Clinical case reports suggest that viscosity, the behavioural tendency to talk repetitively and circumstantially about a restricted range of topics, is common in patients with temporal lobe epilepsy (TLE). Such patients are also reported to exhibit heightened levels of social cohesion, the tendency to become interpersonally "clingy". This "sticky" interpersonal style may be particularly common in TLE patients with a left sided temporal lobe seizure focus. To test this hypothesis, self-report and observer rating scales were developed to assess both viscosity and social cohesion. Subjects consisted of patients with right, left, or bilateral temporal lobe seizure foci, absence or primary generalised tonic-clonic seizures, psychiatric controls (panic disorder patients), and normal controls. Elevations on the viscosity scale were observed primarily in TLE patients with left or bilateral seizure foci. Viscosity scores also correlated with seizure duration and left handedness. No group differences were observed on the social cohesion scale. These findings are consistent with the hypothesis that viscosity results from subtle interictal language disturbances, although other pathogenetic mechanisms are discussed.

Psychiatric aspects of epileptic children and adolescents

Epilepsy is the most prevalent neurological disorder of childhood and adolescence and a very heterogenous disease with a diverse course of illness. It may be a benign disease for the majority of children and adolescents, who recover spontaneously or are managed well medically; however, a sizeable group of children and adolescents with epilepsy, at least one-third, do manifest various difficulties--seizure control, academic, emotional, behavioral, and family problems. As a group, they have a much higher rate of psychiatric disorder than healthy children and children with other chronic illnesses. This review is undertaken to summarize the literature on epilepsy in children and adolescents, especially with respect to epidemiology, developmental and psychiatric problems, and psychiatric treatment issues.

Postictal psychosis after partial complex seizures: a multiple case study

Bouts of unusually frequent partial complex seizures originating in the temporal lobe, that sometimes became secondarily generalized, induced psychotic episodes in 9 patients. In 7, the increase in seizures occurred at a time when antiepileptic drugs (AEDs) were being reduced during intensive EEG monitoring with a view to surgical treatment of intractable epilepsy. According to DSM-III-R criteria, the postictal psychosis resembled an organic delusional syndrome which was paranoid in 7 and schizophreniform in 1 and an organic mood syndrome in 1. A high incidence of ictal fear, of bilateral independent epileptogenic discharge, and of small foreign tissue lesion were unexpected findings and appeared to represent risk factors, especially in patients otherwise handicapped by an epileptic personality disorder. Recognition of postictal psychosis in this setting and in others is important both prognostically and therapeutically. Postictal psychosis does not constitute a contraindication to surgical treatment of epilepsy.

Neuroendocrinology and limbic epilepsy: relationships to psychopathology, seizure variables, and neuropsychological function

Correlations were sought among neuroendocrine, psychopathologic, neuropsychological, and seizure variables in 16 male patients with limbic epilepsy. Plasma prolactin and luteinizing hormone levels were directly correlated with seizure frequency. Plasma prolactin was inversely correlated with thought disorder. Post hoc findings included a strong direct correlation between total plasma testosterone levels and aggression. These relationships may help to elucidate mechanisms related to interictal symptomatology in patients with limbic epilepsy.

Psychopathology and limbic epilepsy: relationship to seizure variables and neuropsychological function

Correlations were sought among psychopathologic, neuropsychological, and seizure variables in 21 patients with limbic epilepsy. Observer-based assessments, such as the Bear-Fedio Inventory, and self-report assessments of psychopathology were used. Self-reported psychotic experiences were associated with increased seizure frequency. Increased religiosity was noted in patients whose epileptic focus included the left side. Increased neuropsychological impairment was associated with several measures of psychopathology, including those related to thought disorder, psychoticism, and affective disturbance.

Psychosocial dimensions of epilepsy: a review of the literature

The literature on psychosocial dimensions of epilepsy has been reviewed utilizing the framework developed by Dodrill et al. (Epilepsia 1980; 21:123-35). Factors considered were family background, emotional adjustment, interpersonal adjustment, vocational adjustment, financial status, adjustment to seizures, and medicine and medical management. The published studies highlighted a number of issues and sometimes rendered varying and contradictory conclusions. In general, epilepsy fosters certain reactions in family members. If negative, these reactions may be detrimental to the person with epilepsy. The association between specific emotional adjustment factors and epilepsy is not conclusive. Studies have been published which support as well as refute this association. Studies indicate that persons with epilepsy experience lower rates of marriage and more sexual difficulties than do nonepileptic persons. Studies report greater unemployment and underemployment in epileptic persons than in the population at large. Studies suggest that some persons with epilepsy manifest an attitude of nonacceptance of self. Some are reluctant to disclose their disability to others. The studies also indicate the presence of a discriminatory attitude by some nonepileptic persons toward epileptic persons. Several factors are associated with successful medical management of epilepsy. The emphasis in research studies with regard to psychosocial aspects of epilepsy focuses predominantly on individual deficiencies rather than on strengths and abilities.

Ego functions in epilepsy

Two groups of epilepsy patients (28 patients with temporal lobe epilepsy and 15 patients with primary generalized epilepsy) entered a study of personality traits related to epilepsy, based on a modification of Bellak's semistructured interview for assessment of ego strength. Two groups of subjects served as controls: 15 patients with a non-neurological but relapsing disorder, psoriasis, and 15 healthy volunteers. Compared with the group of healthy volunteers, a decreased adaptive level of ego functioning was found in the epilepsy groups, regardless of seizure types and EEG findings, and, to a lesser extent, compared with the psoriasis group. Areas of ego functioning most affected were "reality testing", "cognitive functioning", "integrative functioning" and "regulation and control of drives". Patients with more than one type of seizure were the most affected, as were patients who were younger than 15 years when the disease began. The number of anticonvulsants administered did not influence the results. No difference on adaptive level of ego functioning was found between the group with primary generalized epilepsy and the group with temporal lobe epilepsy. Similarly, the temporal lobe epilepsy group with predominantly right-sided and left-sided EEG changes, respectively, showed similar adaptive levels of ego functioning.

The neurological, psychosocial and demographic correlates of hypergraphia in patients with epilepsy

The multiaetiological determinants and correlates of interictal hypergraphia in patients with epilepsy were studied. A variety of neurological, psychosocial and demographic variables were examined in order to determine their relationship to experimental and clinically derived measures of hypergraphia in a sample of 50 patients with epilepsy. The results indicate that hypergraphia is of multifactorial origin in general, with especially strong relationships with measures of psychopathology. These results are related to the larger literature concerned with interictal behavioural change in patients with epilepsy.

Psychopathology in epilepsy: prevalence, phenomenology and management

Epilepsy is associated with interictal behavioral disturbances. The pattern of specific psychopathology differs from that of other chronic diseases because of the higher incidence of psychosis and characterological disorders. Approximately 7 percent of epileptics develop a chronic atypical psychosis with paranoid and affective features, and this may be more common in patients with a definite temporal lobe focus. Brief psychotic episodes occur and are more directly related to cerebral dysrhythmia. A subgroup of epileptics develop specific personality traits, aggressive behaviors under certain circumstances, and hyposexuality. Affective illness and suicide are also prevalent. There are special issues in the management of psychopathology in the setting of epilepsy such as the relative seizure threshold lowering effects of psychotropic drugs and the behavioral effects of altering the seizure control. This article discusses both diagnostic and management aspects of the interictal psychopathology of epilepsy.

Phenomenology of depression in epilepsy

Sixty-six patients with epilepsy and depression were studied. Thirty-four had a family history of psychiatric illness; depression was the most common condition. Assessed using standardised rating scales, the severity of the depression was moderate and was endogenous in approximately 40% of patients. Attendant features were high state and trait anxiety and hostility. The EEGs of the patients and a control group were not significantly different. Patients receiving phenobarbital (PB) were more depressed, whereas those taking carbamazepine (CBZ) were both less depressed and less anxious. The phenomenology of the depression was not clearly influenced by epilepsy variables. We suggest that the depression in patients with epilepsy represents the outcome of multiple factors in genetically predisposed individuals.

Epilepsy and verbosity

Stories were elicited from 29 epileptic patients with generalized, simple partial, and complex partial seizures with bilateral, right, or left foci, and from 32 persons in two control groups. Four older epileptic patients with long histories of left complex partial seizures were verbose. Their stories involved trivial and subjective details, consistent with circumstantiality and suggesting the substrate for a hallucinatory syndrome.

Interictal behavioral features of patients with epilepsy

Three questions are dealt with in this paper. (1) Do patients with epilepsy differ behaviorally from normal control groups and from persons with other medical and neurological conditions with respect to emotional adjustment, and if so, in what ways? (2) Are patients with temporal lobe epilepsy different emotionally or behaviorally from patients with other types of epilepsy? (3) To what degree does underlying brain dysfunction create a substrate for abnormal and maladaptive behavior? A review of the literature reveals the following. Persons with epilepsy demonstrate more emotional and psychiatric problems than normal individuals and more difficulties than other patient groups having nonneurological disorders, but have about the same incidence of these problems as persons with other neurological disorders. Increased emotional and psychiatric problems are not found among patients with temporal lobe epilepsy in comparison to patients with other types of epilepsy, although there are some behavioral peculiarities which appear in a small proportion of these patients. There is a mild tendency for impairment on neuropsychological tests to be associated with emotional and psychiatric problems in epilepsy.

The influence of seizure type and medication on psychiatric symptoms in epileptic patients

The influence of type of seizure and medication on psychological disability was assessed using the Standard Psychiatric Interview in matched epileptic patients. In comparison to patients with idiopathic tonic-clonic seizures, those with temporal lobe epilepsy complained of more irritability and impaired concentration, and were rated as more depressed and slowed up. Compared to patients on phenytoin, those on carbamazepine complained of more sleep disturbance and were more likely to be taking an hypnotic.

Dopaminergic supersensitivity follows ferric chloride-induced limbic seizures

Injection of ferric chloride (FC) into the left amygdala of rats produced limbic seizures that lasted at least 3 weeks. In addition, FC-injected animals demonstrated motor impairment, decreased protesting vocalizations, and spontaneous stereotypies during a behavioral examination. An increase in apomorphine-induced stereotypies was also noted, and weekly administration of apomorphine for 3 weeks potentiated the increase in stereotypies produced by FC injection. These behavioral changes were associated with changes in postsynaptic dopamine D2 receptors. In animals injected only with FC, an increase in the [3H]-spiperone Bmax in the left nucleus accumbens and an increase in Kd in the right nucleus accumbens were noted. In FC-injected animals challenged weekly with apomorphine for 3 weeks, increases in the [3H]-spiperone Bmax in both amygdalae, the left nucleus accumbens, and the right nucleus caudatus and increases in Kd in the left amygdala and right nucleus accumbens were noted. Severance of the anterior commissure at the time of FC injection reversed most of these changes in behavior and dopamine receptor binding. Possible mechanisms for these changes are discussed, as well as the implications of these results for research on limbic dysfunction and psychopathology.

Personality characteristics of epileptic patients: a controlled study of generalized and temporal lobe cases

Patients with left temporal lobe epilepsy (TLE), right TLE, and generalized epilepsy (GE) were compared on a self-report inventory of personal behavior, ideas, and convictions. Distinct personality profiles emerged for the left TLEs and GEs, while the right TLEs responded like neurologically normal individuals. The quality of these profile differences may indicate a contribution of disordered left-hemisphere language mechanisms to the interictal personality syndrome of TLE.