Predicting the psychosocial outcome of epilepsy surgery: A longitudinal perspective on the 'burden of normality'.

Good seizure outcomes and good psychosocial outcomes following epilepsy surgery do not necessarily follow one from the other. This study explored the relationship between several presurgical psychosocial characteristics and postsurgical quality-of-life outcomes. The study aimed to develop the concept of 'the burden of normality' and identify risk factors for a poor psychosocial outcome that could be targeted with ameliorative presurgery cognitive behavioral techniques. Data were collected from 77 epilepsy surgery patients from three UK epilepsy centers and presurgery and postsurgery follow-up data were obtained from 30-34 patients, depending on the measure. Measures were self-report. Postsurgery intervals were determined by the epilepsy surgery care pathway at individual centers. Presurgery poor levels of mental health, poor social functioning, increased belief in illness chronicity, and associating epilepsy with social role limitations were all associated with poor postsurgical quality of life. Adopting an accepting coping strategy presurgery was associated with good postoperative quality of life. Regression analysis showed that a good postsurgical quality of life was positively predicted by a presurgical coping style of being able to make the best of a situation and see challenges in a positive light (i.e., positive reinterpretation and growth from the COPE scale) and negatively predicted by presurgical levels of anxiety. These data are presented as an important step in identifying psychological red flags for an adverse psychosocial outcome to epilepsy surgery, as exemplified by the concept of the 'burden of normality' and specifying targets for preoperative ameliorative psychological advice.

A comparison of emotional and cognitive intelligence in people with and without temporal lobe epilepsy.

Medial temporal lobe structures have been hypothesized to be important in emotional intelligence (EI) and social cognition. There is some evidence associating temporal lobe epilepsy (TLE) with impairments in social cognition. This study aimed to establish whether TLE is also associated with deficits in EI. Sixteen patients with TLE and 14 controls without epilepsy matched for age and current intelligence quotient were compared on measures of EI, recognition of facial expressions of emotion, and distress. Results indicated that patients with TLE showed both impaired EI and impaired recognition of facial expressions. They also reported greater psychological distress, which correlated negatively with EI. It is suggested that some of the psychosocial problems experienced by patients with TLE can be conceptualized as the consequences of deficits in EI, possibly resulting from epilepsy-related disruption to medial temporal lobe functioning.

The base rate of Wada test failure.

Although functional brain imaging can lateralize language functioning and has the potential to assess the functional integrity of the mesial temporal lobe memory structures, imaging protocols are not currently available for clinical use. Assessing the risk of post-epilepsy surgery memory decline is an important part of treatment planning, and the Wada test remains the current technique. The Wada test is invasive and has limitations with respect to sensitivity and specificity. We describe an audit of 141 consecutive Wada test results looking at the base rate of failure and clinical characteristics of failure. The objective was to provide base rate data that support decision making regarding selective use of the Wada test. We conclude that right-handed patients with right temporal lesions who have strong verbal memory are very unlikely to fail and probably do not need to undergo the Wada test. Patients with left temporal lesions are more likely to fail regardless of handedness and regardless of baseline neuropsychological test data. We propose that until functional imaging protocols become available to supersede the Wada test, patients should be considered for the Wada test on a case-by-case basis.

A review of neuropsychological services in the United Kingdom for patients being considered for epilepsy surgery.

We report a review of the current practice of neuropsychologists working within epilepsy surgery services. The aim of the review was to examine areas of diversity and consensus across current national service provision and to examine progress in service delivery since a previous survey in 1994. Sixteen centres provided information via a questionnaire on three areas of clinical practice: pre- and post-surgery neuropsychological protocols; the intracarotid sodium amytal protocol; patient and family expectations and psychological health, in addition to examining aspects of the context of clinical practice such as the role and experience of the psychologist and future service priorities. Findings of the review suggest that, whilst progress has been made towards fulfilling the recommended guidelines for services, there remain a number of areas for development in terms of the provision of a consistent nationwide service delivery approach. Cognitive assessment and the ICSA procedure remain essential components of the neuropsychology service. Assessment of psychological health and quality of life is now carried out by a growing number of centres, although these remain areas for further development. Consensus was found in terms of the need to establish centres of excellence, and to develop appropriate training for neuropsychologists in the field.

Can temporal lobe epilepsy surgery ameliorate accelerated long-term forgetting?

Accelerated long-term forgetting (ALF) is a relatively newly identified phenomenon in neuropsychology which has been associated with temporal lobe epilepsy (TLE). ALF is characterised by intact acquisition and retention of memories over delays of minutes and hours, but abnormally fast forgetting over delays of 24h or more. The causes of ALF are unknown; however disruption of "slow" consolidation processes through seizure activity in the temporal lobes is proposed as a possible explanation. We looked to establish whether seizure control following epilepsy surgery ameliorated ALF in patients with TLE. Parallel sets of verbal and visual stimuli were administered comparing seven TLE patients and 25 healthy controls, matched on key demographic characteristics. Free recall and recognition were assessed at both pre-surgery/time 1 and post-surgery/time 2 at delays of 25 or 45 s, 30 min and one week. The TLE group retained significantly less verbally and visually learned material between 30 min and one week at the pre-surgery assessment than the control group. Comparison of the groups at post-surgery assessment indicated evidence of improved retention in the TLE group for both visual and verbal material, despite reduced initial registration on the verbal sub-tests. Exploratory analysis of individuals indicated heterogeneity in the patient group with regards to the presence/absence of ALF and post-surgical improvement in ALF. The findings offer some support to the theory that ALF is associated with uncontrolled seizures and that elimination of seizures via epilepsy surgery may improve retention by providing a stable environment for "slow" consolidation to occur. However, our results suggest that this is unlikely to be the sole cause and that "slow" consolidation may normally depend also on the integrity of structures within the neocortex or medial temporal lobes. Further investigation of these apparent heterogeneous groups may be informative in further defining the nature and causes of ALF.

Investigation of social and emotion information processing in temporal lobe epilepsy with ictal fear.

This study examined whether patients with temporal lobe epilepsy (TLE) and ictal fear (IF) show emotion recognition deficits similar to those associated with amygdala damage. Three groups of patients (13 with TLE and IF, 14 with TLE and nonfear auras (non-IF), and 10 with idiopathic generalized epilepsy (IGE)) completed tests of visual and face processing, face emotion recognition and social judgment, together with measures of psychological adjustment (Hospital Anxiety and Depression Scale; SCL-90-R) and Quality of Life (QOLIE-31). All three epilepsy groups had fear recognition deficits, with relatively greater impairments in the IF group. Fear recognition deficits were associated with impaired social judgment of trustworthiness, duration of epilepsy, and a measure of quality of life. Social cognition impairments previously associated with amygdala dysfunction are also a feature of the neuropsychology of TLE, and extend the hypothesis in that they may additionally play a role in IGE.