Steven Kemp

Illness perceptions and outcome in mild head injury: a longitudinal study

Background: A range of neuropathological and psychosocial factors have been implicated in the aetiology and maintenance of post-concussional syndrome (PCS), with a growing consensus in the literature that this is a complex, multifactorial condition. The role of patients’ perceptions in PCS has not been examined to date. Objective: This longitudinal study examines the role of illness perceptions in predicting outcome following mild head injury, controlling for severity of injury, post-traumatic stress symptoms, anxiety and depression, using a logistic regression analysis. Method: 73 patients were admitted to an accident and emergency department with mild head injury (Glasgow Coma Scale score 13–15; loss of consciousness <20 min; post-traumatic amnesia <24 h). Data on PCS symptomatology, illness perceptions, post-traumatic stress symptoms, anxiety and depression were collected after the injury and at the 3 month follow-up. Logistic regression analysis was used to evaluate predictors of outcome. Results: Following a mild head injury, symptomatic patients who believe that their symptoms have serious negative consequences on their lives and will continue to do so, are at heightened risk of experiencing significant enduring post-concussional symptoms (p<0.001). Adding measures of severity of injury, post-traumatic stress symptoms, anxiety and depression to the regression model did not improve prediction of outcome. Conclusion: Whatever other physical or psychological factors may be involved, patients’ perceptions of their illness early after head injury play a part in the persistence of PCS.

International consensus clinical practice statements for the treatment of neuropsychiatric conditions associated with epilepsy

In order to address the major impact on quality of life and epilepsy management caused by associated neuropsychiatric conditions, an international consensus group of epileptologists met with the aim of developing clear evidence‐based and practice‐based statements to provide guidance on the management of these conditions. Using a Delphi process, this group prioritized a list of key management areas. These included: depression, anxiety, psychotic disorders, nonepileptic seizures, cognitive dysfunction, antiepileptic drug (AED)–related neurobehavioral disorders, suicidality, disorders in children and adolescents, disorders in children with intellectual disability, and epilepsy surgery. Clinical practice statements were developed for each area and consensus reached among members of the group. The assessment and management of these conditions needs to combine knowledge of psychiatric disorders, knowledge of the impact of epilepsy and its treatment on psychopathology, and an ability to deliver care within epilepsy services. The aim of these statements is to provide guidance on quality care for people with epilepsy that have a range of neuropsychiatric disorders.

Acceptability and effectiveness of a strategy for the communication of the diagnosis of psychogenic nonepileptic seizures

Purpose:  Communicating the diagnosis of psychogenic nonepileptic seizures (PNES) is a challenging task. This study was carried out to assess the acceptability and effectiveness of a new communication procedure consisting of a patient information leaflet and a communication strategy for neurologists.

The influence of cognitive impairment on health-related quality of life in neurological disease

Mitchell AJ, Kemp S, Benito-León J, Reuber M. The influence of cognitive impairment on health-related quality of life in neurological disease. Background: Cognitive impairment is the most consistent neurological complication of acquired and degenerative brain disorders. Historically, most focus was on dementia but now has been broadened to include the important construct of mild cognitive impairment. Methods: Systematic search and review of articles linked quality of life (QoL) and cognitive complications of neurological disorders. We excluded QoL in dementia. Results: Our search identified 249 publications. Most research examined patients with brain tumours, stroke, epilepsy, head injury, Huntingtons disease, motor neuron disease, multiple sclerosis and Parkinsons disease. Results suggested that the majority of patients with epilepsy, motor neuron disease, multiple sclerosis, Parkinsons disease, stroke and head injury have subtle cognitive deficits early in their disease course. These cognitive complaints are often overlooked by clinicians. In many cases, the cognitive impairment is progressive but it can also be relapsing-remitting and in some cases reversible. Despite the importance of severe cognitive impairment in the form of dementia, there is now increasing recognition of a broad spectrum of impairment, including those with subclinical or mild cognitive impairment. Even mild cognitive difficulties can have functional and psychiatric consequences–especially when they are persistent and untreated. Specific cognitive deficits such an inattention, dysexecutive function and processing speed may affect a number of quality of life (QoL) domains. For example, cognitive impairment influences return to work, interpersonal relationships and leisure activities. In addition, fear of future cognitive decline may also impact upon QoL. Conclusions: We recommend further development of simple tools to screen for cognitive impairments in each neurological condition. We also recommend that a thorough cognitive assessment should be a part of routine clinical practice in those caring for individuals with neurological disorders.

Emotional dysregulation, alexithymia, and attachment in psychogenic nonepileptic seizures.

OBJECTIVES Psychogenic nonepileptic seizures (PNESs) are poorly understood and difficult to treat. Research and theory suggest that problems with recognizing, acknowledging, and regulating emotional states (i.e., emotional dysregulation) may contribute to the development and maintenance of PNESs. However, there is a lack of well-controlled studies using dedicated measures of emotional regulation with patients with PNESs. The current study sought to address this gap. METHODS Forty-three patients with PNESs and 24 with epilepsy completed a postal survey comprising measures of emotional dysregulation (Difficulties in Emotion Regulation Scale), alexithymia (Toronto Alexithymia Scale), attachment (Relationship Scales Questionnaire), and psychopathology (Generalized Anxiety Disorder-7; Patient Health Questionnaire-9; Somatoform Dissociation Questionnaire-20). Cluster analysis was used to identify possible subgroups of patients with PNESs characterized by distinct patterns of emotional dysregulation. RESULTS Two clusters of patients with PNESs were identified. The first (n=11) was characterized by higher levels of psychopathology, somatization, alexithymia, and difficulties with most aspects of emotional regulation (including identifying, accepting, and describing feelings, accessing adaptive regulatory strategies, performing goal-directed behaviors, and controlling feelings and actions) compared with the group with epilepsy. The second (n=32) was characterized by relatively high somatization and depression scores but comparatively normal levels of alexithymia and emotional regulation. CONCLUSIONS The findings suggest that patients with PNESs can be divided into at least two meaningful subgroups characterized by distinct psychological profiles, only one of which is characterized by significant problems with emotional dysregulation. Further research is needed to determine whether the relatively normal emotional dysregulation and high somatization scores of some patients with PNESs are due to emotional avoidance or more basic problems with perceptual and behavioral control.

Clinical experience with oral lacosamide as adjunctive therapy in adult patients with uncontrolled epilepsy: A multicentre study in epilepsy clinics in the United Kingdom (UK)

INTRODUCTION Lacosamide (LCS) is a new antiepileptic drug (AED) licensed in the European Union (EU) and United States (US) in 2008. AIMS To evaluate the efficacy and tolerability of add-on LCS in an out-patient epilepsy clinic setting to obtain useful information for everyday practice. METHODS We pooled data retrospectively from the case note of patients with refractory epilepsy in whom LCS had been prescribed in 19 hospitals across the United Kingdom. RESULTS Four hundred and three patients were included (mean age 41.9 years, 50.6% women, 18.1% with learning disabilities (LD)). Mean follow-up (FU) was 11.6 months (range one day to 42 months). Most patients (86.9%) presented with symptomatic partial epilepsy (SPE) and 80% were taking two or more antiepileptic drugs (AEDs) when LCS was added (mean 2, range 0-4). Retention rates were 80% at six months, 68% at one year and 45% at two years. The efficacy of LCS was evaluated at three months and at the final FU. At three months one hundred and eight patients (31.1%) reported ≥ 50% seizure reduction and 32 (9.2%) were seizure free. At the final FU 102 (37.5%) reported ≥ 50% seizures reduction and 28 (9.8%) were seizure free. One hundred and ninety three patients (48.7%) reported adverse effects (AEs). The most frequent were sedation and dizziness, followed by nausea. Lacosamide was discontinued in 150 patients (38%), 60 due to AEs alone. CONCLUSION LCS appears to be an effective and safe AED when used as adjunctive therapy in patients with refractory partial epilepsy.

Psychologic treatment of patients with psychogenic nonepileptic seizures

Psychogenic nonepileptic seizures are relatively common, often disabling and costly to patients and society. Most authorities consider psychologic treatment as the therapeutic intervention of choice. This review is intended primarily for psychologists and therapists who treat patients with psychogenic nonepileptic seizures, and for neurologists who make the diagnosis and wish to find out more about psychologic treatment options. The first section describes the nature and etiology of psychogenic nonepileptic seizures. General questions regarding the psychologic treatment of patients with psychogenic nonepileptic seizures are addressed, before discussing specific therapeutic approaches. The final part summarizes the authors’ views on optimal treatment and the direction of future research.

Clinical experience with adjunctive perampanel in adult patients with uncontrolled epilepsy: A UK and Ireland multicentre study

PURPOSE To derive clinically useful information about the efficacy and tolerability of adjunctive treatment with perampanel for refractory epilepsy in an outpatient setting. METHOD We pooled retrospective casenotes data of adult patients with refractory epilepsy prescribed perampanel from 18 hospitals throughout UK and Ireland. RESULTS Three hundred and ten patients were included (mean age 40.9 [SD=12.0], 50% women, 27.7% with learning disability). The mean duration of epilepsy was 26.7 years (range 2-67 years, SD=13.5) and 91.9% were taking two or more anti-epileptic drugs at the time of perampanel initiation. Mean retention was 6.9 months (range 1 day-22.3 months, SD=4.5). The retention was 86% at 3 months, 71% at 6 months, 47.6% at 12 months and 27% at 18 months. At final follow-up a >50% reduction in seizure frequency was reached in 57.5% of tonic-clonic seizures, 57.4% of complex partial seizures and 43.8% of simple partial seizures. Eleven patients (3.5%) became seizure free. Two hundred and nine patients (67.4%) experienced adverse effects and of these 67% withdrew treatment due to their effects. The most common were sedation, behaviour/mood disturbance, dizziness, and unsteadiness. CONCLUSION Perampanel appears a safe and effective antiepileptic drug when used as adjunctive therapy in patients with uncontrolled partial epilepsy (including those with learning disability), although few patients achieved complete seizure control. Long-term retention was slightly lower than reported rates for other anti-epileptic drugs, potentially due to the highly refractory population. Monitoring for adverse effects on energy levels, mood and behaviour is recommended.

Accelerated long-term forgetting (ALF) and transient epileptic amnesia (TEA): Two cases of epilepsy‐related memory disorder

Temporal lobe epilepsy (TLE) has long been associated with memory impairment. Recently, two specific forms of memory complaint in this population have been identified: accelerated long-term forgetting (ALF) and transient epileptic amnesia (TEA). This paper presents neuropsychological data (standard neuropsychological tests and experimental measures) on two patients who presented in the epilepsy clinic with seemingly similar subjective reports of profound memory difficulties. This paper illustrates the differences between TEA and ALF. Our focus was on measuring long-term forgetting utilizing a novel visual and verbal test protocol, with responses elicited via verbal prompts over the telephone at intervals up to 30 days. Whereas patient SK had neuropsychological test evidence of problems with learning plus ALF at short and long intervals without clinical evidence of TEA, patient EB had clinically convincing TEA without neuropsychological test evidence of ALF. In particular, SK showed accelerated forgetting while EB did not. This detailed case work develops our understanding of ALF measurement and demonstrates that ALF and TEA can be dissociated.

Autobiographical memory and the self in a case of transient epileptic amnesia.

Transient epileptic amnesia (TEA) is characterized by deficits in autobiographical memory (AM). One of the functions of AM is to maintain the self, suggesting that the self may undergo changes as a result of memory loss in temporal lobe epilepsy. To examine this, we used a modification of a task used to assess the relationship between self and memory (the IAM task) in a single case, E.B. Despite complaints of AM loss, E.B. had no difficulty in producing a range of self-images (e.g., I am a husband) and collections of self-defining AMs in support of these statements. E.B. produced fewer episodic memories at times of self-formation, but this did not seem to impact on the maintenance of self. The results support recent work suggesting the self may be maintained in the absence of episodic memory. The application of tasks such as that used here will further elucidate AM impairment in temporal lobe epilepsy.