The impact of epilepsy from the patient's perspective I. Descriptions and subjective perceptions

This study surveyed the perceptions about and subjective experience of 1023 people with epilepsy in two community-based samples: one from a national postal survey; the other callers to the Epilepsy Foundation. Response to a mail survey was 49%. In comparison with US Census Bureau norms, respondents had received less education, were less likely to be employed or married, and came from lower income households. Complex partial seizures were the most prevalent seizure type, but a convulsion had occurred in 61%. Fifty percent of respondents reported incomplete control of their seizure disorder, although 25% of these had a seizure in the prior year. Thirteen percent had a longest inter-seizure interval of a year or greater, 37% of 3 months, 22% of 1 month, 10% of 1 week and 4% of 1 day. Respondents listed uncertainty and fear of having a seizure as the worst thing about having epilepsy. Lifestyle, school, driving, and employment limits were also listed as major problems. When asked to rank a list of potential problems, cognitive impairment was ranked highest. These data indicate that ongoing medical and psychosocial problems continue for those with epilepsy in the view of those questioned and their families, even in a sample where the majority report good control of their epilepsy.

[Status epilepticus with confusional symptomatology]

Non-convulsive confusional status epilepticus (NCSE) is classically separated into two forms on the basis of the ictal EEG, i.e., absence status (AS) and complex partial status epilepticus (CPSE). The diagnosis is difficult on the basis of clinical semiology alone, and requires emergency EEG investigation. Absence status, or 'petit mal' status, is a polymorphic condition that can complicate many epileptic syndromes, and is the most frequently encountered form of NCSE. It is characterized by confusion of varying intensity, associated in 50% of cases with bilateral periocular myoclonias. The EEG shows ictal generalized paroximal activity; normalization is obtained after benzodiazepine injection. In AS, there is a significant nosographic heterogeneity. Four groups can be distinguished: i) typical AS occurs in the context of a generalized idiopathic epilepsy; ii) atypical AS occurs in patients with symptomatic or cryptogenic generalized epilepsies; iii) 'de novo' AS (of late onset) is characterized by toxic or metabolic precipitating factors in middle-aged subjects with no previous history of epilepsy; iv) AS with focal characteristics occurs in subjects with a pre-existing or newly diagnosed partial epilepsy, mostly of extra-temporal origin. The majority of cases are in fact transitional forms between these four groups. CPSE is characterized by continuous or rapidly recurring complex partial seizures which may involve temporal and/or extratemporal regions. Cyclic disturbance of consciousness is characteristic of CPSE of temporal lobe origin, which requires vigorous treatment to prevent recurrence or cognitive sequelae. CPSE of frontal lobe origin is a diagnostic challenge: it is rare, the symptoms are unusual, and the patients should be documented extensively. A focal frontal lesion is revealed in one-third of cases.

Ictus expectoratus: a sign of complex partial seizures usually of non-dominant temporal lobe origin

Spitting (or expectoration) is rarely seen with seizures. In Western society, spitting is a striking behavioral aberration. A 13-year-old child had intermittent agitated behavior, episodes of rage, spitting and confusion lasting up to 2 minutes. He stood up in church and told the preacher to 'shut up and sit down'. Epilepsy monitoring revealed spitting with polysharp and spike seizures resolved over the right temporal lobe. Magnetic resonance imaging revealed a right temporal lobe ganglioglioma. Spitting seizures resolved after resection. Ictal expectoration is rare. It may occur with epigastric aura, nausea, chewing, swallowing and fumbling. Literature review disclosed 17 cases, 12 of which arose from the non-dominant hemisphere. Most regressed with surgery and anticonvulsants.

The efficacy of valproate-lamotrigine comedication in refractory complex partial seizures: evidence for a pharmacodynamic interaction

PURPOSE

To assess the comparative therapeutic value of valproate (VPA), lamotrigine (LTG), and their combination in patients with complex partial seizures resistant to other established antiepileptic drugs (AEDs).

METHODS

After a 3-month prospective baseline, 20 adults with refractory complex partial seizures not exposed previously to VPA and LTG were scheduled to receive three consecutive add-on treatments with VPA, LTG, or their combination, according to an open, response-conditional, crossover design. Each period consisted of a 6- to 12-week dose optimization followed by 3-month evaluation at stabilized serum drug levels. Only patients not responding to one phase proceeded to the next.

RESULTS

A >50% reduction in seizure frequency was observed in three of 20 patients given VPA and in four of 17 patients given LTG. Of the remaining 13 patients, four became seizure free, and an additional four experienced seizure reductions of 62-78% when VPA and LTG were given in combination. Mild tremor was observed in three patients receiving VPA and in all patients taking the VPA--LTG combination. In patients responding to combination therapy, optimized dosages and peak serum levels of both VPA and LTG were lower than those during separate administration.

CONCLUSIONS

A considerable proportion of patients who failed to respond to VPA and LTG separately improved when the two drugs were combined, although serum levels of both agents were lower during combination therapy. Despite methodologic limitations in the nonrandomized treatment sequence, these findings suggest that VPA and LTG exhibit a favorable pharmacodynamic interaction in patients with refractory partial epilepsy. The dosage of both drugs, however, may need to be reduced to minimize the risk of intolerable side effects.

[Cognition, emotion, and behavior. Neuropsychosomatisms and non-neurological paroxysms]

INTRODUCTION

We present neuropsychosomatic disorders diagnosed and treated during the period 1994-1997.

PATIENTS AND METHODS

A total of 83 cases, 24 boys and 59 girls, were selected according to suspected diagnosis. Their ages were in relationship with the psychosomatic disorder. This 83 cases is 10% of neuropediatric assistance in the period. A protocol was designed for disclosing any organic pathology. The psychopedagogic method is based on the PASS theory of intelligence and emotion processing theory of masquerade behavior. The success was defined after a period of, at least, two years of follow-up.

RESULTS

Cephalalgia was the most frequent diagnosis. Language and learning difficulties, attention deficit disorder and pseudo-epilepsy were also frequent. Other diagnoses were: amblyopia, paralysis, pseudo-autism, tic, sphincter disorder, vertigo, mutism and sleep disorder.

DISCUSSION

Concerning differential diagnosis, it must be emphasized that complex partial epilepsy of frontal lobe can mimic psychosomatics disorder as short, less than one minute, automatism. Partial epilepsy of temporal lobe may also mimic psychosomatic disorder but epilepsy does not respond to psychopedagogic remediation. Tumor and migraine must be also disclosed in case of cephalalgia but they do not respond to psychopedagogic remediation. Neurological scientific bases of emotion processing theory are widely explained.

CONCLUSION

Cognition and emotion are functions of the central nervous system so they are competency of neuropediatrician. On the other hand, it is convenient for neuropediatrician to know about behavioral analysis in order to improve diagnosis and economical cost.

Cognitive abilities and adjustment with gabapentin: results of a multisite study

The cognitive and quality of life effects of gabapentin are not yet well explored. While preliminary work in the area has provided positive findings, a large double-blinded study has been needed to explore this area more thoroughly. From 24 sites in North America, 201 adults were studied who had uncontrolled complex partial seizures with or without secondary generalization. Attempts were made to convert each patient from one or two marketed antiepileptic drugs (AEDs) taken in baseline to gabapentin monotherapy (600, 1200, or 2400 mg/day). Tests of cognitive abilities and adjustment were administered at the end of the 8-week baseline period and at the end of the 26-week double-blind treatment period. Analyses of baseline to treatment period changes were conducted for each dose group in comparison with a reference group of placebo-treated patients from another study. In the area of cognitive functioning, no changes in any of the gabapentin groups were found in comparison with the reference group. In the area of adjustment and mood, however, improvement with gabapentin administration was noted on several variables pertaining to emotional and interpersonal adjustment. These results are consistent with findings from previous studies.

[Epilepsy due to mesiotemporal sclerosis in children: 10 cases]

BACKGROUND

Mesio-temporal sclerosis is a frequent and probably underestimated cause of resistant temporal epilepsy in childhood.

PATIENTS AND METHODS

Ten patients originating from West and North-East France are reported in this retrospective study. They were referred for partial temporal epilepsy which had begun between the ages of 3.5 and 15 years. Mesio-temporal sclerosis was diagnosed on MRI (ten cases) and on neuropathological examination (three cases).

RESULTS

Complex partial seizures were noted in all patients, with most frequently fear, abnormal epigastric perception and oro-alimentary automatisms. Social and educational issues were altered due to frequent seizures and amnesic disturbances. An initial event, always a complex febrile seizure, was found in six patients. MRI study showed in all patients unilateral hippocampal atrophy and/or an increase in hippocampal T2 signal intensity on coronal sections. Ictal EEG showed homolateral temporal seizures six times. Hippocampo-amygdalectomy was performed in three patients with a good outcome.

CONCLUSION

Epilepsy associated with mesio-temporal sclerosis belongs to intractable epilepsy in childhood. Early recognition of its symptoms would allow early pre-operative assessment in order to minimize developmental defects due to continuing epilepsy, and adverse cognitive effects of anti-epileptics.

Can patients perform volitional motor acts at the start of a seizure?

A seizure warning device might allow some individuals with partial seizures to protect themselves against consequences of seizures, but a prerequisite is the ability to take volitional action in response to a warning. The authors reviewed consecutive seizures in their epilepsy monitoring unit to determine whether patients could squeeze an event bulb, as instructed, at the start of their seizure. Only complex partial seizures with EEG changes and with the patient on camera were analyzed. Data were obtained from 77 patients, 42 with scalp monitoring and 35 with depth electrodes. Forty-seven percent had a left-hemisphere focus, 42% a right-hemisphere focus, and 11% multifocal seizures. The seizure focus was temporal in 68%. A magnetic resonance imaging consistent with mesial temporal sclerosis was seen in 29% of patients. Overall, 44% of the patients made at least one attempt to reach for the event bulb at the start of their seizures. Among the 72% of patients who gave a history of auras, 53% were able to press the event bulb compared to 20% with no history of auras (P = 0.016). EEG changes occurred a mean of 2.9+/-30.5 seconds after reaching for the bulb for scalp-recorded seizures (n = 20), and 16.2+/-13.7 seconds before behavior for depth-recorded seizures (n = 14, difference significant at P = 0.02). Neither seizure focus nor seizure laterality influenced the ability to press the event bulb. The authors conclude that nearly half of individuals with complex partial seizures can take volitional motor action at the start of their seizure. A method to enhance the intensity and timeliness of a seizure warning would not be wasted.

Violence and epilepsy: a close relation between violence and postictal psychosis

PURPOSE

We investigated the incidence of well-directed violent behavior and suicide attempts in patients with temporal lobe epilepsy, with special attention to postictal psychosis.

METHODS

We compared 57 episodes of postictal psychosis with 62 episodes of acute interictal (or alternative) psychosis and with 134 complex partial seizures. All patients were matched for age and for age at onset of seizures.

RESULTS

The incidence of well-directed violent behavior against human beings was significantly higher (23%) during postictal psychotic episodes than during acute interictal episodes (5%) and postictal confusion (1%). Suicide attempts were also more frequent during postictal psychosis (7%) than during either acute interictal psychosis (2%) or postictal confusion (0%).

CONCLUSIONS

Our study showed that well-directed violent and self-destructive behavior was not a feature of epileptic psychosis in general but a specific hallmark of postictal psychosis.

Reorganization of verbal memory and language: a case of dissociation

Left-to-right reorganization of verbal memory following early left hemisphere damage has been reported in patients whose expressive language is governed by the right hemisphere. We present a case in which verbal memory performance was intact, despite severe left mesial temporal damage, and despite aphasia on left internal carotid sodium amytal ablation. The distribution and degree of left mesial temporal damage was assessed visually and quantitatively on MRI. These findings raise the possibility that verbal memory may shift to the language-nondominant hemisphere as a result of early left mesial temporal damage.

Psychopathology in pediatric complex partial and primary generalized epilepsy

Structured psychiatric interviews were administered to 60 children with complex partial seizure disorder (CPS), 40 children with primary generalized epilepsy with absences (PGE), and 48 control children, aged 5 to 16 years. Significantly more patients with epilepsy had psychiatric diagnoses compared with the control children. There were no statistically significant differences, however, in the number of patients with CPS and PGE with psychiatric diagnoses. Other than a schizophrenia-like psychosis found only in the patients with CPS, the two groups of patients had similar psychiatric diagnoses. The presence of psychopathology was related to significantly lower IQ scores and socioeconomic status, but not to seizure-related factors. These findings suggest that the psychopathology of children with CPS and PGE reflects different subtle neuropsychological deficits.

Ictal cognitive assessment of partial seizures and pseudoseizures

BACKGROUND

Previous studies suggest that responsiveness is impaired during complex partial seizures (CPS) and pseudoseizures (PS); however, to our knowledge, there has been no systematic comparison using both response and memory testing.

OBJECTIVE

To compare CPS with PS using ictal cognitive assessment (ICA) of responsiveness and memory.

PATIENTS AND METHODS

We used a nonautomated method of ICA by bedside observers, consisting of family members and staff, during video electroencephalographic monitoring to test responsiveness and memory during the ictal phase in 245 events. We assessed the adequacy of testing and compared the testing results in 31 patients during CPS and 13 patients during PS.

RESULTS

The ictal presentation of a command was successful in 58% of the events. The ictal presentation of at least 2 memory items with testing for recall after orientation was adequate in 57% of events. Impaired responsiveness was shown during both CPS and PS. However, some response was detected during 48% of PS compared with 18% of CPS (P<.01). Memory items were recalled during 63% of PS but during only 4% of CPS (P<.001). The International Classification of Epileptic Seizures remained useful, but in 11 events (8%), distinguishing complex from simple partial seizures was difficult. Recall of various types of stimuli (aural-verbal vs visual-pictorial) during ICA did not correlate with the side or location of the seizure focus, but this may have been confounded by the rarity of any memory recall during CPS.

CONCLUSIONS

Ictal cognitive assessment by bedside observers is practical and provides the interaction necessary for properly classifying seizures; ICA, especially memory, may help to distinguish CPS from PS.

Awareness and responsiveness during partial seizures

We examined the impairment of consciousness during partial seizures (PS) arising from various brain sites according to the operational definition of the international classification, i.e., altered awareness and/or responsiveness. The subjects were 142 patients who underwent intracranial EEG evaluation and subsequent resective surgery. First, the patients were examined to determine whether they usually had been partially or completely aware of their seizures. Second, spontaneous habitual seizures that had been videotaped with simultaneous intracranial EEG recording were reviewed to determine responsiveness and recall during ictal behavioral alterations. In all, 114 patients were partially or completely aware of their seizures. Patients who tended not to be aware of their seizures were those with frontal lobe epilepsy (FLE) with extensive epileptogenic regions on the language nondominant side and those with temporal lobe epilepsy (TLE) with seizure origin in the lateral cortex of the language dominant side. Of the 21 patients with FLE, 88 with TLE, and 4 with occipital lobe epilepsy, 7, 22, and 2 patients responded to stimuli during the seizure, respectively, but only 11 of the patients with FLE and none of the other patients could recall the stimuli applied during the behavioral alterations. Bilateralization of seizure discharges correlated with impaired responsiveness. According to the International Classification, about half of patients with FLE had only simple partial seizures (SPS) and the other patients had complex partial seizures (CPS). Altered awareness and/or responsiveness occurred in most habitual partial seizures in our subjects. The term "complex" appears to be useful in clinical practice, although the contents of ictal behavior and the site or side of seizure origin are not implied.

Epileptic seizures and pseudoseizures from the viewpoint of the hierarchy of consciousness

Epileptic seizures and pseudoseizures in temporal lobe epilepsies were studied from the viewpoint of the hierarchy of consciousness. Twenty-two patients with temporal lobe epilepsies (TLE) who showed true amnesia or impairment of consciousness developing from the dreamy state, even though their actions and movement continued, were selected among 160 patients with TLE, nine patients with manifested pseudoseizures, pseudoseizure status, and complex partial seizure status (CPSE) were investigated. Twelve patients in whom impairment of consciousness followed the dreamy state recognized their own existence and maintained some self-directed consciousness. The other 10 patients with amnesia were aware of their goals. Furthermore, pseudostatus ranged from epileptic seizures during pseudoseizure status to pseudoseizures during status epilepticus (SE). In some cases of CPS, awareness and self-directed consciousness were only partially pseudoseizures, disorders of self-directed consciousness are assumed to influence awareness and arousal.

Independent recovery of memory and language functioning during the Intracarotid Sodium Amytal Test

Memory and language recovery during the Intracarotid Sodium Amytal Test (IAP) was investigated in 49 left-hemisphere-dominant patients with unilateral temporal epileptic seizure foci. Memory was assessed by presenting items (words, objects, and faces) immediately after injection, and testing for recognition memory 10 min after motoric recovery. To assess language the patients responded verbally to the same items during memory presentation. Memory for the individual items was found to be independent of their presentation order and language functioning was impaired only with the dominant-hemisphere injection, recovering during the presentation of the memory items. These results suggest that the encoding of material remains at a constant level throughout the initial active phase of the IAP, whereas language functioning recovers independently.

Effect of acute administration of various 5-HT receptor agonists on focal hippocampal seizures in freely moving rats

In this study, we assessed the effects of the acute administration of various 5-HT receptor agonists on hippocampal partial seizures generated by low-frequency electrical stimulation in male Wistar rats. The seizure threshold and severity were determined by measuring the pulse number threshold and primary and secondary afterdischarges and the latency of secondary discharge was also determined. The administration (0.1-1 mg/kg, i.p.) of either the 5-HT1A receptor agonist, 8-hydroxy-2-(di-n-aminopropyl)tetralin (8-OH-DPAT), or the selective 5-HT3 receptor agonist, 4-amino-(6-chloro-2-pyridyl)-1-piperidine (SR 57227A, 0.3-3 mg/kg, i.p.), did not alter any of the seizure parameters compared to those in vehicle-treated animals. Similarly, the administration of 0.3 and 1 mg/kg, i.p., of the 5-HT2A,C receptor agonist, (+/-)-2,5-dimethoxy-4-iodophenyl-2-aminopropane (DOI), did not alter any of the seizure parameters, whereas 3 mg/kg significantly decreased the latency of the secondary afterdischarge compared to that in vehicle-treated animals. The selective serotonin reuptake inhibitor, (+/-)-fluoxetine (2 mg/kg, i.p.), significantly increased the pulse number threshold and decreased the primary afterdischarge duration compared to those in vehicle-treated animals. In contrast, higher doses (6 or 20 mg/kg, i.p.) of fluoxetine did not significantly alter any of the seizure parameters measured. These results suggest that, in this model, stimulation of 5-HT1A, 5-HT2A,C and 5-HT3 receptors does not alter seizure threshold or severity and that the blockade of 5-HT uptake produced by a low dose of fluoxetine appears to increase seizure threshold and decrease seizure severity.

Complex partial and secondarily generalized seizure patients: cognitive functioning prior to treatment with antiepileptic medication. VA Epilepsy Cooperative Study 264 Group

This investigation of cognitive functioning in patients with symptomatic localization-related (partial) epilepsy prior to administration of antiepileptic medication is part of a nationwide prospective, double-blind study of drug efficacy and longitudinal changes in cognition associated with seizure disorders. Recently-diagnosed patients with complex partial or secondarily generalized tonic clonic seizures, equated for age, education and IQ, were compared with normal controls on a battery of neuropsychological tests: verbal and figural memory measures (Rey auditory verbal learning test, Rey Osterrieth complex figure), and a brief behavioral toxicity battery comprising measures of motor function, concentration and mental flexibility (Lafayette grooved pegboard, controlled word association test, Stroop, paced auditory serial addition test [PASAT]). Control subjects perform significantly better than both groups of seizure patients on several measures of motor speed/integration and memory, specifically the pegboard and the RAVLT learning (3-5) and recall trials. Secondarily generalized seizure patients show greatest impairment. They perform significantly worse than patients with complex partial seizures and control subjects on the controlled word association test and the most demanding Stroop color word trial, both measures of concentration and mental flexibility. These findings document deficits in memory as well as concentration and motor function in complex partial and in secondarily generalized seizure patients prior to treatment with antiepileptic medication.

Elevations of complex partial epileptic-like experiences during increased geomagnetic activity for women reporting "premenstrual syndrome"

Responses to the frequency of complex partial epileptic-like experiences were recorded every second day by 12 women for at least two months per individual. Five (41%) of the women displayed significant increases (effect sizes between 6% and 17%) in the numbers of these experiences when the daily geomagnetic activity exceeded 40 nT. The results were consistent with the hypothesis that a spectrum of experiences and behaviours, associated with limbic lability, can be enhanced by environmental stimuli correlated with perturbations of the geomagnetic field.

Anxiogenic-like consequences in animal models of complex partial seizures

Several kinds of psychiatric symptoms (anxiety, depression, schizophrenia) have been associated with epilepsies, and clinical data suggest that patients with seizures involving limbic structures are the most prone to develop behavioural disorders between the seizures (i.e. interictally). Studying the neurobiological mechanisms that underlie these symptoms is difficult in humans because of different interfering factors (e.g. psychosocial difficulties, pharmacological side-effects, lesions), which can be avoided in animal models. Using repetitive electrical stimulations (kindling) or local applications of a neuroexcitotoxin in limbic structures (mainly the amygdala and hippocampus), several authors have reported lasting changes of emotional reactivity in cats and rats. These changes appear as anxiety-related reactions expressed as a hyperdefensiveness in the cat, or a reduction of spontaneous exploration in tests predictive of anxiogenic effects in the rat. Some neuroplasticity processes known to develop during epileptogenesis (neuronal-hyperexcitability, modulation of GABA/benzodiazepine transmission) may participate in these lasting changes of behaviour, especially in structures involved in the control of fear-promoted reactions (amygdala, periaqueductal grey matter). In addition, endogenous control systems may also play a critical role in the occurrence of interictal behavioural disorders.

[Coincidence of epilepsy and Asperger syndrome. Case report and review]

Asperger syndrome is an autistic disorder and was first described by Hans Asperger in 1944 without further acceptance in the literature over almost four decades. Following several publications in the 1980s, for the disorder became more widely known and was first introduced into ICD-10 and DSM-IV as a new diagnosis in 1988 and 1994, respectively. The etiology is unknown. We present a female patient with typical features of Asperger syndrome, suffering also from epilepsy and internal medical disorders. The associated diseases, diagnostic criteria and possible therapeutic options are discussed.

Chronic stimulation of the left vagus nerve: cognitive motor effects

BACKGROUND

Early studies of cognitive motor control have shown deficits in complex reaction time tests of epileptic subjects. The purpose of this efficacy study was to determine whether chronic (28 months) stimulation of the left vagus nerve (VNS) to control seizures increased these deficits in 6 epileptic subjects with intractable complex partial seizures.

METHODS

Subjects were assessed for simple reaction time, Test A, and subsequent Tests B and C which involved more complex cognitive strategies. Tests were done pre-operatively (SI) and at intervals, 6-8 weeks (S2-S3), and at 6 month intervals (S4-S6) over a 28 month period. Data were collected and collated on an Apple II E computer (Apple, Cupertino CA. U.S.A.) and on electronic switch pad. Data were analyzed using a repeated measures analysis of covariance technique with 2 within subject factors, day, and time of day.

RESULTS

2/11 cognitive measures showed a statistically significant difference. Error rate associated with Test A (simple reaction time) significantly decreased for the factor of day (repeated visits) p = .01. For Test C, error rates decreased in the afternoon (p = .03). This test involved the subjects ability to respond quickly to one signal while simultaneously ignoring a second signal. Data analysis of the covariate showed that the effects of VNS are weak in comparison to baseline differences and the frequency of nerve stimulation negatively predicts the number of wrong errors. High frequency stimulation results showed fewer errors than low frequency stimulation T = -2.31, p = .03.

CONCLUSION

Chronic stimulation of the left vagus nerve to control seizure activity does not impair cognitive motor control.

"I would kill in God's name:" role of sex, weekly church attendance, report of a religious experience, and limbic lability

Data collected during the last 15 years for the Personal Philosophy Inventory from 1.48 thousand university men (n = 629) and women (n = 853) were analyzed to discern the response characteristics of individuals who stated "yes" to Item 136 "If God told me to kill, I would do it in His name." The percentage (7%, range between 2% and 8% per year) of affirmative responses did not change significantly over time. The odds ratio for men: women for an affirmative response was 1.4:1. As predicted a four-way interaction for sex, weekly church attendance, history of a religious experience, and elevated complex partial epileptic-like signs was statistically significant. Of the men who reported a religious experience, attended church weekly, and displayed elevated complex partial epileptic like signs (5.7% of all males), 44% stated they would kill another person if God told them to do so.