Cesare Maria Cornaggia

Risk factors for fatal and nonfatal repetition of suicide attempts: a literature review

Objectives This review aimed to identify the evidence for predictors of repetition of suicide attempts, and more specifically for subsequent completed suicide. Methods We conducted a literature search of PubMed and Embase between January 1, 1991 and December 31, 2009, and we excluded studies investigating only special populations (eg, male and female only, children and adolescents, elderly, a specific psychiatric disorder) and studies with sample size fewer than 50 patients. Results The strongest predictor of a repeated attempt is a previous attempt, followed by being a victim of sexual abuse, poor global functioning, having a psychiatric disorder, being on psychiatric treatment, depression, anxiety, and alcohol abuse or dependence. For other variables examined (Caucasian ethnicity, having a criminal record, having any mood disorders, bad family environment, and impulsivity) there are indications for a putative correlation as well. For completed suicide, the strongest predictors are older age, suicide ideation, and history of suicide attempt. Living alone, male sex, and alcohol abuse are weakly predictive with a positive correlation (but sustained by very scarce data) for poor impulsivity and a somatic diagnosis. Conclusion It is difficult to find predictors for repetition of nonfatal suicide attempts, and even more difficult to identify predictors of completed suicide. Suicide ideation and alcohol or substance abuse/dependence, which are, along with depression, the most consistent predictors for initial nonfatal attempt and suicide, are not consistently reported to be very strong predictors for nonfatal repetition.

Correlation between cognition and behavior in epilepsy.

Summary:  Cognitive function is more frequently impaired in people with epilepsy than in the general population, and the degree of cognitive impairment varies according to the epilepsy syndrome. Behavioral disorders are also more frequent in people with epilepsy than in individuals who do not have epilepsy. Behavioral disturbance is observed more frequently in people with drug‐resistant epilepsy, frequent seizures, and/or associated neurological or mental abnormalities. In children and adolescents, many data suggest a close link between behavior/cognition and some specific epilepsy syndromes. For example, aspects of mood, behavior, personality, and cognition may be related to temporal lobe epilepsy or juvenile myoclonic epilepsy. Behavioral disorders may precede, occur with, or follow a diagnosis of epilepsy; they differ between children and adults. Predictors of behavioral disorders in children with epilepsy are the epilepsy itself, treatment, the underlying lesion, and personal reactions to epilepsy. More specifically, conditions in which behavioral disorders may be associated with epilepsy include depression, psychosis, particular personality traits, aggression, anxiety, and attention deficit and hyperactivity disorder.

Idiopathic Generalized Epilepsies of Adolescence

Summary:  The prevalence of idiopathic generalized epilepsies (IGEs) has been assessed as being 15–20% of all epilepsies. The seizure types in IGEs are typical absences, myoclonic jerks, and generalized tonic–clonic seizures (TCS), alone or in varying combinations and with variable severity. The seizures tend to be more frequent on awakening and with sleep deprivation. This group of clinical conditions includes among others, age‐related epilepsy syndromes of adolescence such as juvenile absence epilepsy (JAE), juvenile myoclonic epilepsy (JME), and IGE with generalized TCS or epilepsy with grand mal on awakening (EGMA). The classification of IGEs follows two schools of thought; one maintains that IGEs are a group of different and separate syndromes while the other suggests that IGEs are one biological continuum. Patients with IGEs may have mild impairment of cognitive functions, especially verbal memory and other frontal lobe functions, despite a normal IQ, and some seem to have characteristic personality traits, although further studies are needed to support this theory. They appear to lack a degree of self‐control, to neglect their physical needs, and are poorly compliant with therapy. Some patients become obstinate and are impressionable. The cognitive and behavioral aspects of these patients suggest an involvement of frontal lobes.

Learning Disorders in Epilepsy

Summary:  Learning disorders (LD) are disorders interfering with academic performance or with daily living activities requiring reading, writing, or mathematical abilities in subjects with a normal intelligence quotient. The prevalence of LD in the general population has been found to be 2–10% and reading disorders are the most frequent subtype. Epilepsy is one of the commonest neurological disorders in childhood with an estimated prevalence in 4–5/1,000. Epilepsy is considered to be idiopathic or cryptogenic in approximately two‐thirds of cases. LD are more common in people with epilepsy than in the general population: about 25% of patients with epilepsy are said to have LD. Various psychosocial, medication‐related, and epilepsy‐related factors may be associated with LD in epilepsy. LD can be either permanent or state‐dependent. Permanent LD are caused by a brain lesion and/or a stable brain dysfunction. In contrast, state‐dependent LD are potentially reversible and treatable; they are caused by epilepsy‐related factors. If allowed to persist for a long period, a state‐dependent LD may become permanent.

Epilepsy and everyday life risks

Despite its favorable outcome in up to 90% of patients, epilepsy is still considered to carry a higher than normal risk of morbidity and accidents. Knowledge of the everyday life risks (illnesses, acc

Epilepsy and family expressed emotion: results of a prospective study

PURPOSE To verify the emotional components expressed by the relatives of adult patients with a diagnosis of epilepsy, and whether they are related to adjustment to the illness and the course of the illness over time. METHODS We studied a consecutive sample of 43 outpatients suffering from epilepsy and 43 key relatives using the Camberwell Family Interview (CFI), with the expressed emotion (EE) of the relatives being rated at baseline (T0). EE refers to a construct representing some key aspects of interpersonal relationships: the relatives were assigned to the high-EE group if they scored 3 or more on the emotional over involvement (EOI) scale, or showed hostility, or made 6 or more critical comments. The patients were clinically evaluated at baseline and for 1 year of appropriate treatment by an epileptologist who was blinded to the EE ratings. They also completed STAI XI, STAI X2 and Becks Depression Inventory at baseline. RESULTS Twenty-six relatives (60%) were rated as showing a high degree of EE. In the 12-month follow-up study, high EE and high EOI were found to be associated with a significantly higher seizure frequency than that recorded for the patients living in low-EE households (p<0.05). The patients from households assessed as reflecting a high degree of criticism showed poor drug compliance (p<0.01), whereas those with relatives assessed as having a high degree of warmth showed better clinical and pharmacological compliance (p<0.01). High family criticism scores also correlated with higher study entry levels of depression (p<0.05) and trait and state anxiety (p<0.05) among the patients. CONCLUSIONS The study findings highlight the impact of particular components of the family emotional climate on the clinical course and psychological adjustment of patients with epilepsy.

Psychogenic non-epileptic seizures: so-called psychiatric comorbidity and underlying defense mechanisms

In Diagnostic and Statistical Manual of Mental Disorders, fifth edition, psychogenic non-epileptic seizures (PNES) do not have a unique classification as they can be found within different categories: conversion, dissociative, and somatization disorders. The ICD-10, instead, considers PNES within dissociative disorders, merging the dissociative disorders and conversion disorders, although the underlying defense mechanisms are different. The literature data show that PNES are associated with cluster B (mainly borderline) personality disorders and/or to people with depressive or anxiety disorders. Defense mechanisms in patients with PNES with a prevalence of anxious/depressive symptoms are of “neurotic” type; their goal is to lead to a “split”, either vertical (dissociation) or horizontal (repression). The majority of patients with this type of PNES have alexithymia traits, meaning that they had difficulties in feeling or perceiving emotions. In subjects where PNES are associated with a borderline personality, in which the symbolic function is lost, the defense mechanisms are of a more archaic nature (denial). PNES with different underlying defense mechanisms have different prognoses (despite similar severity of PNES) and need usually a different treatment (pharmacological or psychological). Thus, it appears superfluous to talk about psychiatric comorbidity, since PNES are a different symptomatic expression of specific psychiatric disorders.

Validation of a novel classification model of psychogenic nonepileptic seizures by video-EEG analysis and a machine learning approach.

The aim of this study was to validate a novel classification for the diagnosis of PNESs. Fifty-five PNES video-EEG recordings were retrospectively analyzed by four epileptologists and one psychiatrist in a blind manner and classified into four distinct groups: Hypermotor (H), Akinetic (A), Focal Motor (FM), and with Subjective Symptoms (SS). Eleven signs and symptoms, which are frequently found in PNESs, were chosen for statistical validation of our classification. An artificial neural network (ANN) analyzed PNES video recordings based on the signs and symptoms mentioned above. By comparing results produced by the ANN with classifications given by examiners, we were able to understand whether such classification was objective and generalizable. Through accordance metrics based on signs and symptoms (range: 0-100%), we found that most of the seizures belonging to class A showed a high degree of accordance (mean±SD=73%±5%); a similar pattern was found for class SS (80% slightly lower accordance was reported for class H (58%±18%)), with a minimum of 30% in some cases. Low agreement arose from the FM group. Seizures were univocally assigned to a given class in 83.6% of seizures. The ANN classified PNESs in the same way as visual examination in 86.7%. Agreement between ANN classification and visual classification reached 83.3% (SD=17.8%) accordance for class H, 100% (SD=22%) for class A, 83.3% (SD=21.2%) for class SS, and 50% (SD=19.52%) for class FM. This is the first study in which the validity of a new PNES classification was established and reached in two different ways. Video-EEG evaluation needs to be performed by an experienced clinician, but later on, it may be fed into ANN analysis, whose feedback will provide guidance for differential diagnosis. Our analysis, supported by the ML approach, showed that this model of classification could be objectively performed by video-EEG examination.

Partial seizures with affective semiology versus pavor nocturnus

Sudden nocturnal events with an affective semiology may have various etiologies, such as nocturnal panic attacks, nightmares, pavor nocturnus and/or different types of focal epileptic seizures, particularly in children. We describe the case of a normally developed boy who, at the age of two years, experienced nocturnal paroxysmal events that occurred about one hour after falling asleep and lasted up to 15 minutes. The clinical picture was characterized by sudden arousal, fear, inconsolable crying and an apparently voluntary search for his mother. The state of consciousness was basically maintained, and the inter-ictal EEG pattern showed independent bilateral centro-temporal spikes and spike-and-wave complexes. The child had a family history of benign partial epilepsy of childhood with rolandic spikes, and the paroxysmal events remitted after valproic acid treatment. This case report highlights the difficulties in the differential diagnosis of panic attacks, nightmares, pavor nocturnus and focal nocturnal epileptic seizures, especially those arising from the temporal and frontal lobes.

Psychiatric events in epilepsy

Psychiatric events are thought to be more frequent in people with epileptic seizures than in the general population. However, inter-ictal psychiatric events attributable to epilepsy remain controversial. The aim of the present study was to evaluate the occurrence of psychiatric events in a population of fairly unselected patients with epilepsy and in the general population, and the correlation between psychiatric complaints and selected demographic and disease characteristics. The survey was part of a multicentre prospective cohort study of everyday life risks conducted in eight European countries and comparing referral children and adults with epilepsy referred to secondary/tertiary centers to age- and sex-matched non-epileptic controls. Nine hundred and fifty-one patients with epilepsy and 909 controls were studied. Each patient and his/her control received a diary to record any accident or illness, with severity, circumstances, causes, consequences, and (for the cases) the possible relation to a seizure. The follow-up period ranged between 1 and 2 years. Fifty-eight psychiatric events occurred in 25 patients (2.6%) and 88 in 19 controls (2.1%). Housewives (9.3%) and unemployed persons (4.1%) were mostly affected. No correlation was found between psychiatric events, demographic and disease characteristics. Our results suggest that people with epilepsy if unselected are not at higher risk for psychiatric disorders than the general population.