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.

Impact of depressed mood on neuropsychological status in temporal lobe epilepsy.

OBJECTIVES: Depression is a common psychiatric complication of temporal lobe epilepsy. This study examined the effect of depressed mood on neuropsychological performance among patients with chronic temporal lobe epilepsy. METHODS: Seventy consecutive surgery candidates for medication resistant complex partial seizures of unilateral temporal lobe origin were assessed for psychiatric symptoms and underwent comprehensive neuropsychological assessment. RESULTS: Standardised psychiatric interview disclosed that 34% of the patient sample exhibited significant depression. Controlling for seizure frequency, patients with comorbid depression at the time of neuropsychological assessment exhibited significantly poorer performance on measures of intelligence, language, visuoperceptual ability, memory, and executive function. Within lateralised temporal lobe epilepsy groups, the adverse effects of depression on cognitive function were greater in patients with left temporal lobe compared with those with right temporal lobe epilepsy. In addition, depression seemed to be underrecognised and undertreated as none of the patients with epilepsy and comorbid depression were treated for their psychiatric condition at the time of admission for monitoring. CONCLUSIONS: Depression, a common psychiatric comorbidity among patients with chronic temporal lobe epilepsy, seems to be undertreated and to have adverse effects on cognitive functioning.

Dysphoric disorders and paroxysmal affects: recognition and treatment of epilepsy-related psychiatric disorders.

Interictal dysphoric disorder is an intermittent and pleiomorphic affective-somatoform disorder that presumably occurs as a result of inhibitory mechanisms in chronic mesial temporal lobe epilepsy. Treatment with antidepressant medication, enhanced if necessary with small doses of an atypical antipsychotic, tends to be highly effective. The dysphoric disorder also occurs in the absence of epilepsy in a subictal variation, particularly in patients with brain lesions and as premenstrual dysphoric disorder. The paroxysmal affects, ranging from irritability through anger to rage, play a major role in interictal dysphoric disorder. Their manifestation among patients with mesial temporal lobe epilepsy is counterbalanced by the fact that these individuals tend to be highly ethical and religious. The paroxysmal affects that may emerge with vehemence during episodes of interictal dysphoric disorder play a role in all people, differing in prominence among individuals. For a comprehensive view of the psychiatric aspects of epilepsy, the important premodern findings are reviewed together with recent ones.

Treatment of the interictal psychoses.

BACKGROUND: The interictal "schizophrenia-like" psychoses of epilepsy conventionally are treated with antipsychotic medication with uncertain results. In patients with these psychoses, a preceding and concomitant dysphoric disorder usually can be documented. Effectiveness of the pharmacologic treatment by the combination of drugs that is effective for severe interictal dysphoric disorders is demonstrated in a series of patients with interictal psychosis. METHOD: Patients were treated with the combination of a tricyclic antidepressant and a selective serotonin reuptake inhibitor, enhanced if necessary by a small amount of the atypical neuroleptic risperidone. The series consisted of 8 consecutive patients with interictal psychosis seen over a 20-month period. Two additional patients seen over the past 10 years who required a different therapeutic intervention were also included. RESULTS: Five of the 8 consecutive patients achieved full remission of their psychosis; 3 patients could not be reached for the full treatment effort. One patient with a malignant psychosis had been treated successfully (prior to the series reported) by surgical removal of a left frontal epileptogenic zone; a second patient (treated after the series) recovered only upon elimination of the antiepileptic drug that had suppressed clinical seizures but had resulted in an alternating psychosis. CONCLUSION: Interictal psychoses can be viewed as severe interictal dysphoric disorders with psychotic features. The same combination of psychotropic medication that is effective for severe interictal dysphoric disorders serves as the primary therapy for interictal psychoses. The interictal psychiatric disorders presumably result from seizure-suppressing mechanisms that are the targets of the proconvulsant drugs. Upon suppression of seizures, some patients with interictal psychosis may require modification of the antiepileptic medication responsible for excessive inhibition. Complete surgical removal of the epileptogenic zone can eliminate a chronic interictal psychosis upon postoperative fading of inhibitory mechanisms.

Evidence supporting the temporal lobe epilepsy personality syndrome.

A deepening of emotionality with a serious, highly ethical, and spiritual demeanor has been described by clinicians as a positive personality change among patients with chronic mesial temporal lobe epilepsy. Some of these patients tend to be particularly orderly and detailed in their speech and actions (viscosity) and often experience a relative decrease in sexual interest and arousal. These personality changes, distinct from personality changes noted in any other individuals, are subtle in the majority of patients with chronic epilepsy. Patients with the described personality changes may also develop intermittent symptoms of an interictal dysphoric disorder, with episodes of irritable moods that contrast with a predominantly good-natured attitude and for which the patients will be remorseful. The Bear-Fedio Inventory needs to be further modified before it can serve as an adequate instrument for assessing the prevailing personality changes and the intermittent dysphoric symptoms.

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.

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

PURPOSE: To determine the incidence of psychiatric disorders before and after surgical treatment for partial epilepsy and to document the effectiveness of their treatment. METHODS: Fifty consecutive patients treated surgically for focal epilepsy (44 temporal and six frontal) were evaluated by established neuropsychiatric methods before surgery and over a mean period of 2 years after surgery. The patients with interictal dysphoric disorders, with or without psychotic episodes, were treated with tricyclic antidepressant medication alone or combined with serotonin selective reuptake inhibitors and, if necessary, with the addition of risperidone. RESULTS: Before surgery, 25 (57%) of the 44 patients with temporal lobe epilepsy had dysphoric disorders. After surgery, 17 (39%) of the 44 patients experienced either de novo psychiatric complications (six psychotic episodes, six dysphoric disorders, and two depressive episodes) or exacerbation of preoperative dysphoric disorder (three patients). Eight previously intact patients of the 19 (42%) developed dysphoric disorders after surgery that were significantly related to recurrence of seizures. All psychiatric complications occurred in the first 2 months after surgery, except for the six patients intact before surgery, who had a recurrence of seizures. A significant predictor of ultimate excellent psychiatric outcome was complete absence of seizures after surgery. All postoperative psychiatric complications remitted on treatment with psychotropic medication in the compliant patients. CONCLUSIONS: An exceptional psychiatric morbidity is associated with the months after temporal lobectomy. Possible pathogenetic mechanisms are discussed. Antidepressant drugs are very effective in treating the psychiatric disorders of chronic epilepsy; their use in conjunction with the surgical treatment of epilepsy appears to be crucial for the overall positive outcome of a significant number of patients.

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.

Antidepressant and double antidepressant treatment for the affective disorder of epilepsy.

BACKGROUND: About half of all patients with chronic epilepsy experience an intermittent and polysymptomatic affective disorder; fewer than 10% suffer from interictal psychotic episodes. The affective disorder responds well to treatment with tricyclic antidepressant medication. The interictal psychosis tends to develop among those with severe affective disorder, responds poorly to antipsychotic medication, and has been more difficult to treat. METHOD: At the Epi-Care Center, Memphis, Tennessee, we have recently begun to treat refractory cases, both nonresponders with affective disorder and those with interictal psychosis, with the combination of a tricyclic antidepressant (TCA) and a serotonin selective reuptake inhibitor (SSRI). The double antidepressant treatment of all previously intractable patients with interictal affective disorder seen over a 20-month period at the Epi-Care Center is reported here. RESULTS: The outcome of the novel treatment for the most severe psychiatric disorders of epilepsy has been highly satisfactory: 15 (68%) of 22 previously unresponsive patients with affective disorder were excellent or good responders. CONCLUSION: Antidepressants are the psychotropic drugs of choice for the affective disorder of epilepsy and can be effective in combined form (TCA and SSRI) for otherwise intractable patients. The paradoxical therapeutic effects of proconvulsant drugs in epilepsy conform with the hypothesis that the psychiatric complications of chronic epilepsy result from the development of seizure-suppressing mechanisms that can be mitigated by antidepressants.

Psychiatric morbidity in seizure patients on a neurodiagnostic monitoring unit.

This study aimed to clarify prevalence and type of psychiatric disorders among 97 consecutive patients with seizures who were admitted for neurodiagnostic monitoring. Of the 97 patients, 33 (34%) had an atypical mood disorder, 21 (22%) had pseudoseizures, and 9 (9%) had other psychiatric disorders, for a total of 63 (65%) in need of psychiatric treatment. Patients with the atypical mood disorder had predominantly depressive symptoms, which occurred intermittently, were associated with episodes of irritability, and alternated with briefer euphoric moods. Anxiety and phobic symptoms occurred less often. The existence of an epilepsy-specific mood disorder is suggested.

[Intravaginal PgE2 administration for inducing labor in premature rupture of fetal membranes]. / Intravaginale Pg-E2-Gabe zur Geburtseinleitung bei vorzeitigem Blasensprung.

In a prospective study, 121 patients with spontaneous rupture of the membranes of greater than 6 hours duration and unfavourable Bishop-Score (less than 6) were stimulated with 3 mg vaginal prostaglandin-E2-tablets. All patients started labour. Only one patient had a hyperstimulation which was corrected with betamimetics. There were no systemic side effects. Almost 90% of the women delivered on the first day. The rate of the Caesarean sections was low. There was no case of intraamniotic infection; the foetal outcome was good. In conclusion, vaginal prostaglandin-E2-tablets are safe to use in spontaneous rupture of the membranes.

The fate of World War II veterans with posttraumatic seizures.

Of 244 men who, as the result of a brain wound sustained in World War II, had had one or more convulsive seizures, 101 have died. Except for men who succumbed in the first decade of complications of the wounding--infection, systemic or mental disease, status epilepticus, etc--the cause of death was similar to that of men of similar age in the general population. Of the men whose status is known, 74% have had no unconscious attacks in the past ten years or in the ten years before their death. The absence of seizures is not related to the continued ingestion of anticonvulsant medication. Approximately 25% of the men have had varying degrees of mental deterioration. The death rate of men with posttraumatic epilepsy is higher than that of normal men. Wounds of the right cerebral hemisphere seem to shorten the life span more than similar injuries of the left hemisphere.

A multimethod evaluation of the MMPI in a chronic pain patient sample.

Previous reports on the use of the MMPI with chronic pain patients have produced a variety of results. No single configural feature or scale identifies the chronic pain patient, regardless of the origin or verifiability of the etiology of the pain. Elevations on the neurotic triad occur frequently, but do not have the specificity of more recently reported chronic-pain subtypes on the MMPI. The present nonexperimental study (N = 72) provides an example of a multi-method analysis of a carefully selected sample of chronic pain patients without physical findings. Blind clinical analysis, simple two-point code aggregation, and multivariate profile methods were used and produced similar subtypes of the sample and understanding of the data. The obtained sample subtypes were similar to those found in other studies and were hypothesized to be related to each other along an underlying continuum of what might be depression. Further research is needed to facilitate understanding of the causation of chronic pain of obscure origin.

"Chronic pain as a variant of depressive disease". A rejoinder.

The pain-prone disorder as a discrete psychobiological entity was defined on the basis of clinical evaluation, including observation of characteristic premorbid traits, psychological testing, inferred psychodynamic characteristics, a particular family history, and biological markers such as response to antidepressant medication. It is discussed in relation to the complaints of pain found in patients diagnosed primarily as depressive. The points made in the article by Turk and Salovey (J. Nerv . Ment . Dis. 172: 398-404, 1984) are considered item by item.