Laura S. Boylan

Depression but not seizure frequency predicts quality of life in treatment-resistant epilepsy

Background: The two-thirds of patients with epilepsy who become seizure-free have a quality of life (QOL) similar to the general population. The major treatment challenge is patients with refractory epilepsy. Whereas neurologists typically focus on seizure reduction in the treatment of these patients, results of studies relating seizure frequency to QOL are conflicting. As depression is associated with reduced QOL in epilepsy and antiepileptic medications (AEDs) can cause depression, it is important to determine the relative roles of depression and seizure frequency in QOL in refractory epilepsy. Methods: Prospective evaluation was conducted of patients with refractory epilepsy being admitted to an inpatient video-EEG monitoring unit. The impact of clinical variables (age, sex, marital status, seizure frequency, duration and type of seizure disorder, seizure localization, number of AEDs, depression) on QOL was analyzed. Results: Depression was a powerful predictor of QOL (n = 122, β = −35.8, p < 0.0001). No other variable predicted QOL. Depression was common (54%), severe (19% with suicidal thoughts), underdiagnosed (37%), and largely untreated (17% on antidepressants). Conclusions: Treatment of depression may be inadequately prioritized in the management of intractable epilepsy.

Behavioral Indices in Medical Care Outcome: The Working Alliance, Adherence, and Related Factors

BackgroundThe working alliance has been shown to be a consistent predictor of patient outcome and satisfaction in psychotherapy. This study examines the role of the working alliance and related behavioral indices in predicting medical outcome.ObjectiveCognitive and emotional dimensions of the physician–patient relationship were examined in relation to patients’ ratings of physician empathy, physician multicultural competence, perceived utility of treatment, and patients’ adherence self-efficacy. These factors were then examined as part of a theoretical framework using path analyses to explain patient self-reported adherence to and satisfaction with treatment.DesignThe study was based on an ex-post facto field correlation design.ParticipantsOne hundred fifty-two adult outpatients from a neurology clinic at Bellevue Hospital, a large municipal hospital in New York City, participated in the study.InterventionsSurveys given to participants.MeasurementsWe used the following measurements: Physician–Patient Working Alliance Scale, Perceived Utility Scale, Treatment Adherence Self-Efficacy Scale, Medical Outcome Study Adherence Scale, Physician Empathy Questionnaire, Physician Multicultural Competence Questionnaire, Medical Patient Satisfaction Questionnaire.Main ResultsThe effect sizes for adherence are between 0.07 and 0.21 and for satisfaction between 0.10 to >0.50. Regression and path analyses showed that ratings of physician multicultural competence and patient adherence self-efficacy beliefs predicted patient adherence (SB = 0.34) and (SB = 0.30) and satisfaction (SB = 0.18) and (SB = 0.12), respectively. Working alliance ratings also predicted patient satisfaction (SB = 0.49).ConclusionsPsychological and interpersonal dimensions of medical care are related to patient adherence and satisfaction. Medical care providers may be able to use these dimensions to target and improve health care outcomes.

Peri-Ictal Behavioral and Cognitive Changes.

Peri-ictal behavioral and cognitive changes contribute substantially to disability and distress among people with epilepsy. Psychosis, depression, and suicide may all occur as complications of seizures. Greater appreciation and understanding of the peri-ictal period is clinically important and might open novel therapeutic windows. At the same time this period provides a model for understanding basic mechanisms underlying mood and thought disorders and the substrates of cognition, volition, emotion, and consciousness. This review will discuss behavioral and cognitive antecedents of seizures, including the preictal milieu, reflex seizures, and self-induced seizures. Behavioral and cognitive treatment approaches that have been undertaken are reviewed. Both acute and delayed postictal emotional, behavioral, and cognitive changes will be discussed. Finally, possible mechanisms by which epileptic brain activity and behavior may modify each other are considered.

Psychiatric uses of antiepileptic treatments

Antiepileptic drugs (AEDs) possess potent negative or positive psychotropic effects. Clear evidence of benefit exists for valproate, carbamazepine, and lamotrigine in bipolar disorder. Reports of benefit from various AEDs in mood, anxiety, impulse control, and personality disorder are reviewed. Further research is needed to clarify which patients are likely to benefit. Clinicians must closely attend to the ongoing risk/benefit analysis and consider possible iatrogenic worsening of neuropsychiatric symptoms.

Developmental apraxia arising from neonatal brachial plexus palsy

To the Editor: We read with interest the report by Brown et al.1 suggesting the presence of a developmental apraxia among children following neonatal brachial plexus injury. We have recently seen a patient whose history also suggests that apraxia may result from weakness. A 61-year-old woman with a normal birth and development was healthy until becoming ill with polio at age 4 years. She recovered the ability to walk after several years, but was left with bifacial weakness, dysphonia, bilateral hand …

Auras are frequent in idiopathic generalized epilepsy

The occurrence of an aura is often considered evidence of a partial rather than an idiopathic generalized epilepsy syndrome. The authors examined this hypothesis by prospectively recording reports of auras by patients being admitted for video-EEG monitoring. Auras were equally common (70%) among patients with idiopathic generalized epilepsy as they were among those with localization-related epilepsy. Presence of an aura is not a reliable indicator of localization-related epilepsy.

Beyond the Unexplainable Pain Relational World of Patients With Somatization Syndromes

Abstract Somatization syndromes are highly prevalent disorders with unknown etiology and are challenging to treat. Integrating previous findings on alexithymia, attachment, and trauma, we hypothesized that somatization syndromes are associated with a specific internal representation of relationships—the unmet need for closeness with others (desire for interpersonal closeness combined with the fear of being rejected, hurt, or abandoned). Twenty patients with DSM-IV somatization syndromes and 20 well-matched healthy controls completed the Relationship Anecdotes Paradigm/Core Conflictual Relationship Themes interview and measures of interpersonal relatedness, alexithymia, and history of trauma. The results showed that the unmet need for closeness with others was the main internal representation of relationships in 90% of the patients and in only 10% of controls; it was also the strongest predictor of somatization syndrome diagnosis. This suggests that somatization syndromes are strongly associated with the interpersonal representation of the unmet need for closeness with others, which has direct implications for their treatment and future research on their etiology.

Unbalanced statistical analysis of combined divalproex and antipsychotic therapy for schizophrenia.

Unbalanced Statistical Analysis of Combined Divalproex and Antipsychotic Therapy for Schizophrenia

Nonequivalence of equivalence methods.

We thank Drs Lang and Obeso for their perspectives on our article. As described in our article and their letter, the mechanisms underlying neurodegenerative diseases are complex and therefore require multiple different treatment strategies. Because Alzheimer’s disease, Huntington’s disease, amyotrophic lateral sclerosis, spinal muscular atrophy, and Parkinson’s disease (PD) are therapeutically challenging disorders, there is increasing interest in cellular therapies. Current research is centered on the ability of stem and progenitor cells to provide direct replacement of diseased or lost cells, enhance neuronal circuitry, and enrich the local neuronal environment. Clearly, it is a combination of these factors that contributes to the attractiveness of stem cells as a potential therapy for complex neurodegenerative disorders, including PD. We fully agree with Drs Lang and Obeso that PD is characterized by a complex loss of cell types and pathways. Yet while multiple cell types are affected in PD, classical approaches to cellular therapies over the past 2 decades have focused on replacement of lost dopaminergic neurons. This has yielded promising results in vivo and modest functional improvements in patients. In a review article, we contend that we should provide the state of current research, and improving dopaminergic neuronal replacement remains the topic of numerous preclinical and clinical studies for PD. Given the complexity of PD pathogenesis, however, we agree with Drs Lang and Obeso that current and future research should focus on the use of cellular approaches to support essential circuitry and all affected cell types in PD. These multifaceted roles for emerging cellular therapies represent highly important and promising mechanisms of neuroprotection for PD. Most likely, combining cellular replacement with multidimensional support is essential for neuroprotection not only to dopaminergic neurons but to all other cell types and neuronal pathways affected by PD. Overall, the capacity of stem cell technologies to treat neurodegenerative diseases is still a relatively new concept, and much work remains to be done before these approaches progress into realistic and tangible clinical treatments and cures. We acknowledge that there are remaining issues to address and that it can take over a decade to translate promising treatments to the clinic. With continued advances in stem cell technologies and continued comprehension of mechanisms responsible for disease onset and progression, however, we can learn from previous results and evolve new innovative approaches for treating neurodegenerative disorders to maximize the potential of stem cell therapies and support the growing public hope.

Postictal laughter following absence status epilepticus

Acute pathologic neurologic laughter has been described as an ictal phenomenon in epilepsy, as a result of electrical brain stimulation to the cortex and to deep brain structures, in brain tumors, and in stroke. We report what is, to our knowledge, the first report of a case of postictal pathologic laughter. Previously diagnosed with medically refractory complex partial seizures, our patient was admitted to the hospital with phenytoin toxicity. During video-EEG monitoring she experienced multiple brief absence seizures as well as a prolonged episode of absence status epilepticus. Immediately following cessation of the seizure she began to laugh. Her laughter was mirthful and infectious. This lasted several minutes and was followed immediately by several minutes of crying and then a return to normal. We propose that diffuse cortical inhibition led to release of subcortical structures involved in emotional expression. Possible neural substrates of laughter are discussed.