Dietrich Blumer

Psychiatric outcome of temporal lobectomy for epilepsy: incidence and treatment of psychiatric complications.

Summary: Purpose: To determine the incidence of psychiatric disorders before and after surgical treatment for partial epilepsy and to document the effectiveness of their treatment.

The classification of neuropsychiatric disorders in epilepsy: A proposal by the ILAE Commission on Psychobiology of Epilepsy

The classification of psychiatric disorders in epilepsy has evolved considerably from the first attempts in the 19th century. A dedicated subcommission of the ILAE Commission on Psychobiology of Epilepsy (now the Commission on Neuropsychiatric Aspects) has developed this classification proposal. The aim of this proposal is to separate disorders comorbid with epilepsy and those that reflect ongoing epileptiform activity from epilepsy-specific disorders, and to attempt to subclassify the epilepsy-specific disorders alone. Further, the classification of epilepsy-specific psychiatric disorders has largely followed their relationship to the ictus, with factors such as relationship to antiepileptic drug (AED) change being coded as additional information. Finally, this proposal presents a clinical and descriptive system of classification rather than an etiological classification on the grounds that there is currently inadequate information for the latter approach to be employed globally.

Catatonia and the neuroleptics: Psychobiologic significance of remote and recent findings ☆

The previously common occurrence of catatonic schizophrenia and catatonic symptoms among schizophrenic patients has diminished sharply; catatonic symptoms now occur more frequently in association with severe affective disorders or with general medical conditions. Catatonia is generally viewed as a peculiar and puzzling syndrome and attracts limited attention. Yet significant catatonic symptoms tend to be present in close to 10% of patients admitted to psychiatric inpatient facilities. The dynamic significance of catatonia can be recognized by considering the original biologic role of catatonia in schizophrenia as an opposite to the paranoid disorder. Szondi viewed catatonia as an attempt at self-healing of the paranoid psychosis with its threatening total expansion, by extreme constriction of the ego. The previously predominant primary association of catatonia with schizophrenia has been eclipsed as neuroleptics have supplanted the endogenous self-healing attempt of catatonia, preventing the occurrence of catatonic symptoms in schizophrenia. Neuroleptics in fact duplicate or approximate the symptoms of catatonia by producing mental immobilization, hypokinesis (parkinsonism and dystonia), hyperkinesis (akathisia), and pernicious catatonia in the modern guise of the neuroleptic malignant syndrome (NMS). Patients with past or present catatonic symptoms are particularly vulnerable to NMS, and treatment of catatonia requires avoidance of neuroleptics and the use of benzodiazepines or electroconvulsive therapy (ECT). The extreme negativism and constriction of consciousness in catatonia suggest a primary role of the frontal lobes, with secondary involvement of the extrapyramidal system and its movement disorders. In an attempt to integrate clinical, psychologic, neuropharmacologic, and neurochemical findings, a modern dynamic neuropsychiatry must appreciate the major significance of catatonia.

Pharmacologic treatment of psychiatric disorders associated with epilepsy

A disorder termed temporal lobe syndrome (TLS) has been identified among psychiatric patients. It consists of organic traits suggesting a temporal lobe dysfunction, subtle mental changes characteristic of the interictal phase of TLE, and most prominently of an atypical, labile, and pleomorphic psychopathology. The TLS responds to treatment with carbamazepine and often requires the addition of an antidepressant. A series of 19 patients with epilepsy and TLS were treated with carbamazepine, combined at times with valproate for a generalized seizure component, and a modest amount of antidepressant. Ten patients achieved a remission of their psychiatric disorder, coinciding with a full or near remission of seizures. Only three patients failed to show significant improvement. All six patients who did not present with seizures of temporal lobe origin achieved complete remissions, whereas only 4 of the 13 patients with TLE achieved a remission of their TLS. The TLS is viewed as a merely reactive manifestation in the former group and as part of a more chronic process (a discharging temporal-limbic focus) in the latter. Pharmacologic treatment of the TLS associated with epilepsy can be highly effective but requires a unified approach across the specialities of neurology and psychiatry.

Major Psychiatric Disorders Subsequent to Treating Epilepsy by Vagus Nerve Stimulation

Purpose. The goal of this work was documentation of incidence, phenomenology, pathogenesis, and treatment of psychiatric disorders occurring subsequent to treating epilepsy by vagus nerve stimulation (VNS).Methods. In a series of 81 patients treated by VNS, all patients who developed major psychiatric complications underwent systematic psychiatric evaluation and treatment with psychotropic medication; VNS was modified if necessary.Results. After the seizure frequency was reduced by at least 75%, 7 of 81 patients (9%) developed major psychiatric disorders: Six became severely dysphoric (5 with catastrophic rage and 4 with psychotic symptoms), and one became psychotic. All 7 patients had experienced dysphoric disorders and 2 had experienced psychotic episodes prior to the VNS treatment. Five patients had frequent daily seizures prior to treatment. Remission or satisfactory improvement was achieved with psychotropic medication in 6 patients, aided by decreasing or interrupting VNS in two patients. One patient was noncompliant and suffered a fatal outcome.Conclusion. Severe interictal dysphoric disorders associated with catastrophic rage and psychotic episodes may develop on suppressing seizures by VNS in patients with previous epilepsy-related psychiatric disorders. Patients with multiple daily seizures may be more vulnerable to this occurrence. The phenomenon corresponds to the common finding of interictal dysphoric and psychotic symptoms emerging when inhibitory mechanisms predominate (alternative psychiatric disorders in the absence of seizures, or forced normalization of the EEG). The dysphoric symptom of catastrophic rage appears to occur more often on seizure suppression by VNS than by antiepileptic drugs. Psychiatric intervention, primarily with antidepressant medication, must be available to secure a good outcome; decrease of VNS may occasionally be required.

Postictal Depression: Significance for the Treatment of the Neurobehavioral Disorder of Epilepsy

The wide range of depressive and other neurobehavioral disorders of epilepsy can be effectively treated with modest doses of tricyclic antidepressants. Three in a series of 19 patients treated with tricyclics for their neurobehavioral disorders displayed postictal depression, and the observations clarify the relationship of seizure disorder and moods. Postictal and interictal mood changes appear to result from the same process and can be ascribed to the engagement of inhibitory mechanisms. Severity of the postictal depression is explained by the marked enhancement of inhibitory mechanisms on their ictal engagement. The tricyclics exhibit a broad-spectrum effect on the neurobehavioral disorders of epilepsy by a mode of action different from their traditional effect in depressive disorders. They appear to mitigate inhibitory ictal and interictal mechanisms at doses presenting no risk to seizure control.

To what extent do premenstrual and interictal dysphoric disorder overlap? Significance for therapy.

BACKGROUND Premenstrual dysphoria has shown a significant relationship to epilepsy, and its symptoms correspond to those of the interictal dysphoric disorder. The established treatment for interictal dysphoric disorder is explored as an effective treatment for premenstrual dysphoria. METHODS Women with premenstrual dysphoria (the majority with epilepsy) were evaluated and treated systematically. RESULTS Premenstrual disorder responded well to the combination of antidepressant and antiepileptic medication. CONCLUSION Concordance of symptomatology between interictal and premenstrual dysphoric disorder may extend to treatment. LIMITATIONS The treatment needs to be evaluated in a large series of women without epilepsy. CLINICAL RELEVANCE A novel understanding and treatment of premenstrual dysphoria is suggested.

Treatment of patients with coexisting epileptic and nonepileptic seizures

A majority of studies have reported a rate of concurrence of epileptic seizures (ESs) in patients with nonepileptic seizures (NESs) of about 10-18%. We explored the relationship between the two paroxysmal disorders (ESs and NESs) in a series of patients with both, and report a treatment for these patients that proved remarkably effective: reduction of the dose of antiepileptic drug to the minimum required to achieve optimal freedom from seizures. NESs are hypothesized to have a psychobiological basis, and it has been proposed that they be recognized as posttraumatic startle seizures. Excessive suppression of epileptic paroxysmal activity appears to favor the expression of posttraumatic paroxysmal activity in patients with both paroxysmal disorders, and the manifestation of ESs and NESs tends to alternate. Of etiological significance is the finding that the patients commonly have both a personal history of trauma and a family history of epilepsy.

Electroconvulsive treatment for nonepileptic seizure disorders

Because of its striking prevalence among females, the paroxysmal disorder presenting with nonepileptic seizures was termed hysteria in premodern times. In our time, the disorder has remained widely misunderstood and mistreated. The diagnostic early history of painful traumatic events as the source of the nonepileptic seizures is hidden by the shame of the victim and remains ignored. Early effective psychotherapeutic intervention is rarely carried out. Antiepileptic treatment is commonly initiated, and tends to worsen the seizure condition, which commonly becomes chronic. Key evidence from our treatment of patients with both epileptic and nonepileptic seizures had shown that low doses of antiepileptic drugs were required, because the patients markedly improved as some epileptic seizures were allowed to occur. This prompted our use of electroconvulsive treatment for a select series of 18 patients with the most severe chronic nonepileptic seizure condition. This treatment proved remarkably effective for 11 of the 15 patients who tolerated the treatment. Together with their seizures, the patients had had bodily pains, depressive moods, and often anxiety. Their disorder can be clearly distinguished from ordinary depression, and the remarkable effect of electroconvulsive treatment in its treatment seems to be in accordance with premodern views of a polarity between the two paroxysmal disorders epilepsy and hysteria. Further studies of our topic are called for.

De Novo Nonepileptic Seizures after Cranial Surgery for Epilepsy: Incidence and Risk Factors.

We evaluated the incidence of de novo nonepileptic seizures (NES), confirmed by EEG monitoring, after cranial surgery for intractable epilepsy in 228 surgery patients. Eight patients (3.5%) developed de novo NES at 6 weeks to 6 years (mean, 23 months) after surgery. Six had undergone a resection and two complete callosotomy. They did not differ from a larger surgical group with respect to sex, side of surgery, age at onset, or duration of epilepsy, Full Scale Intelligence Quotient, seizure outcome, or preoperative interictal dysphoric disorder (IDD), but there was a significant excess of postoperative IDD and operative complications (bone flap infections); the callosotomy patients had marked hemisphere disconnection syndromes. Repeat EEG videotelemetry monitoring is important to detect postoperative NES so that inappropriate therapeutic measures may be avoided. Risk factors may be exacerbation or persistence of IDD and surgical complications. The etiology of NES is discussed.