The relationship of psychiatric illnesses and seizures

Cognitive impairment in epilepsy patients and its correlations

OBJECTIVE

Epilepsy is a severe disease in which seizures play the leading role. Striking clinical manifestations of the attacks take most of the attention of healthcare professionals. Apart from epilepsy itself, it is well known that epilepsy patients may also have psychiatric comorbidities. These disorders, such as anxiety and depression, are mostly thought to be related to epileptic seizures or antiepileptic medications. In clinical practice, cognitive impairment is another disrupted area of interest in epileptic patients. Our study aimed to detect this deterioration and its correlations with mood disorders and epileptic disease features such as seizure frequency and illness duration.

MATERIALS AND METHODS

After obtaining verbal and written consent, we enrolled 52 epilepsy patients in our study. A short demographic form indicating their gender, epileptic disease features, and medication usage information was completed for each patient. The Quick Mild Cognitive Impairment Screen (QMCI) test, the Hamilton Anxiety Rating Scale (Ham-A), and the Hospital Anxiety and Depression Scale (HADS) were applied by an experienced psychologist. Abnormal brain magnetic resonance imaging findings (e.g., encephalomalacia, large arachnoid cysts, a considerable amount of white matter gliotic lesions, neoplastic or vascular space-occupying lesions, hippocampal malformations), vitamin and electrolyte imbalances, other chronic diseases as well as thyroid dysfunction were considered as exclusion criteria since they might interfere with cognition. We excluded abnormalities to this extent because we wanted to acquire a homogenous sampling population without structural disadvantages. Thus, we could be able to determine slight changes in cognition properly.

RESULTS

We found decreased cognitive scores directly proportional to lower education level, higher seizure frequency, longer disease duration, generalized tonic-clonic (GTC) type of seizure, and antiepileptic polytherapy. Also, complying with the literature, a high frequency of depression was found in our study group. Interestingly, decreased anxiety levels of the patients were statistically related to higher seizure frequency, which may indicate adaptive mechanisms to frequent seizures. Finally, a multivariate regression analysis revealed a significant negative impact of GTC type of seizure on cognition.

CONCLUSION

Epilepsy and epileptic seizures affect cognition negatively. Thus, newly diagnosed epilepsy patients should be assessed for cognitive status as soon as possible. This assessment will allow epileptologists to understand future deteriorations in their patients' cognition. In our study, it is shown that QMCI is an effective and practical way to assess the cognitive statuses of epilepsy patients.

The relationship between mood and anxiety and cognitive phenotypes in adults with pharmacoresistant temporal lobe epilepsy

OBJECTIVE

Patients with temporal lobe epilepsy (TLE) are often at a high risk for cognitive and psychiatric comorbidities. Several cognitive phenotypes have been identified in TLE, but it is unclear how phenotypes relate to psychiatric comorbidities, such as anxiety and depression. This observational study investigated the relationship between cognitive phenotypes and psychiatric symptomatology in TLE.

METHODS

A total of 826 adults (age = 40.3, 55% female) with pharmacoresistant TLE completed a neuropsychological evaluation that included at least two measures from five cognitive domains to derive International Classification of Cognitive Disorders in Epilepsy (IC-CoDE) cognitive phenotypes (i.e., intact, single-domain impairment, bi-domain impairment, generalized impairment). Participants also completed screening measures for depression and anxiety. Psychiatric history and medication data were extracted from electronic health records. Multivariable proportional odds logistic regression models examined the relationship between IC-CoDE phenotypes and psychiatric variables after controlling for relevant covariates.

RESULTS

Patients with elevated depressive symptoms had a greater odds of demonstrating increasingly worse cognitive phenotypes than patients without significant depressive symptomatology (odds ratio [OR] = 1.123-1.993, all corrected p's < .05). Number of psychotropic (OR = 1.584, p < .05) and anti-seizure medications (OR = 1.507, p < .001), use of anti-seizure medications with mood-worsening effects (OR = 1.748, p = .005), and history of a psychiatric diagnosis (OR = 1.928, p < .05) also increased the odds of a more severe cognitive phenotype, while anxiety symptoms were unrelated.

SIGNIFICANCE

This study demonstrates that psychiatric factors are not only associated with function in specific cognitive domains but also with the pattern and extent of deficits across cognitive domains. Results suggest that depressive symptoms and medications are strongly related to cognitive phenotype in adults with TLE and support the inclusion of these factors as diagnostic modifiers for cognitive phenotypes in future work. Longitudinal studies that incorporate neuroimaging findings are warranted to further our understanding of the complex relationships between cognition, mood, and seizures and to determine whether non-pharmacologic treatment of mood symptoms alters cognitive phenotype.

Association of Neighborhood Deprivation With Cognitive and Mood Outcomes in Adults With Pharmacoresistant Temporal Lobe Epilepsy

BACKGROUND AND OBJECTIVES

Temporal lobe epilepsy (TLE) is the most common adult form of epilepsy and is associated with a high risk of cognitive deficits and depressed mood. However, little is known about the role of environmental factors on cognition and mood in TLE. This cross-sectional study examined the relationship between neighborhood deprivation and neuropsychological function in adults with TLE.

METHODS

Neuropsychological data were obtained from a clinical registry of patients with TLE and included measures of intelligence, attention, processing speed, language, executive function, visuospatial skills, verbal/visual memory, depression, and anxiety. Home addresses were used to calculate the Area Deprivation Index (ADI) for each individual, which were separated into quintiles (i.e., quintile 1 = least disadvantaged and quintile 5 = most disadvantaged). Kruskal-Wallis tests compared quintile groups on cognitive domain scores and mood and anxiety scores. Multivariable regression models, with and without ADI, were estimated for overall cognitive phenotype and for mood and anxiety scores.

RESULTS

A total of 800 patients (median age 38 years; 58% female) met all inclusion criteria. Effects of disadvantage (increasing ADI) were observed across nearly all measured cognitive domains and with significant increases in symptoms of depression and anxiety. Furthermore, patients in more disadvantaged ADI quintiles had increased odds of a worse cognitive phenotype (p = 0.013). Patients who self-identified as members of minoritized groups were overrepresented in the most disadvantaged ADI quintiles and were 2.91 (95% CI 1.87-4.54) times more likely to be in a severe cognitive phenotype than non-Hispanic White individuals (p < 0.001). However, accounting for ADI attenuated this relationship, suggesting neighborhood deprivation may account for some of the relationship between race/ethnicity and cognitive phenotype (ADI-adjusted proportional odds ratio 1.82, 95% CI 1.37-2.42).

DISCUSSION

These findings highlight the importance of environmental factors and regional characteristics in neuropsychological studies of epilepsy. There are many potential mechanisms by which neighborhood disadvantage can adversely affect cognition (e.g., fewer educational opportunities, limited access to health care, food insecurity/poor nutrition, and greater medical comorbidities). Future research will seek to investigate these potential mechanisms and determine whether structural and functional alterations in the brain moderate the relationship between ADI and cognition.

The Timing, Nature, and Range of Neurobehavioral Comorbidities in Juvenile Myoclonic Epilepsy

BACKGROUND

Accumulating evidence suggests that considerable cognitive and psychiatric comorbidity is associated with juvenile myoclonic epilepsy, for which the etiology remains controversial. Our goal was to comprehensively characterize the status of multiple neurobehavioral comorbidities in youth with new- or recent-onset juvenile myoclonic epilepsy, before effects of chronic seizures and medications.

METHODS

A total of 111 children aged eight to 18 years (41 new- or recent-onset juvenile myoclonic epilepsy and 70 first-degree cousin controls) underwent neuropsychological assessment (attention, executive, verbal, perceptual, speed), structured review of need for supportive academic services, parent reports of behavior and executive function (Child Behavior Checklist and Behavior Rating Inventory of Executive Function), and formal structured psychiatric interview and diagnosis (Kiddie Schedule for Affective Disorders and Schizophrenia-Present and Lifetime Version).

RESULTS

Children with juvenile myoclonic epilepsy performed worse than controls across all tested cognitive domains (F(1,105) = 3.85, P < 0.01), utilized more academic services (47% versus 19%, P = 0.002), had more parent-reported behavioral problems and dysexecutive function with lower competence (P < 0.001), and had a higher prevalence of current Axis I diagnoses (attention-deficit/hyperactivity disorder, depression, and anxiety; 54% versus 23%, P = 0.001). Academic and psychiatric problems occurred antecedent to epilepsy onset compared with comparable timeline in controls.

CONCLUSION

Comprehensive assessment of cognitive, academic, behavioral, and psychiatric comorbidities in youth with new- or recent-onset juvenile myoclonic epilepsy reveals a pattern of significantly increased neurobehavioral comorbidities across a broad spectrum of areas. These early evident comorbidities are of clear clinical importance with worrisome implications for future cognitive, behavioral, and social function. It is important for health care providers to avoid delays in intervention by assessing potential comorbidities early in the course of the disorder to optimize their patients' social, academic and behavioral progress.

Effects of surgical side and site on psychological symptoms following epilepsy surgery in adults

This retrospective study examined the potential role of side and site of surgery in psychological symptom change after epilepsy surgery and determined the base rate of psychological change at the individual level. Two-hundred twenty-eight adults completed the Personality Assessment Inventory (PAI) before and after temporal (TLR; n=190) or frontal lobe resection (FLR; n=38). Repeated measures ANOVAs with bootstrapping examined differences in psychological outcome as a function of surgical site separately in patients who underwent left- versus right-sided resections. Individual's PAI score changes were then used to determine the prevalence of clinically meaningful postoperative symptom change. Following left-sided resections, there were significant group-by-time interactions on Somatic Complaints, Anxiety, and Anxiety Related Disorders. There was also a trend in this direction on the Depression scale. TLR patients endorsed greater preoperative symptoms than FLR patients on all of these scales, except the Somatic Complaints scale. After surgery, TLR patients reported symptom improvement on all four scales, while scores of FLR patients remained relatively stable over time. Endorsement of Mania-related symptoms increased in both TLR and FLR groups from pre-to post-surgical testing. Following right-sided resections, both groups endorsed symptom improvements on Somatic Complaints, Anxiety, and Depression scales following surgery. In addition, the TLR group endorsed more Mania-related symptoms than the FLR group regardless of time. Patterns of meaningful change in individual patients were generally consistent with group findings, with the most frequent improvements observed following TLR. However, there were a small subset of patients who reported symptom exacerbation after surgery. Our results suggest that surgical lateralization and localization are important factors in postoperative psychological outcome and highlight the importance of considering psychological change at the individual patient level. Further research is needed to identify potential risk factors for symptom exacerbation to aid in preoperative counseling and identify those patients most in need of postoperative psychological surveillance.

Cognitive behavioural interventions for depression in chronic neurological conditions: a systematic review

OBJECTIVE

Chronic neurological conditions (CNCs) affect over one million people in the UK alone. Individuals with CNCs endure an increased prevalence of comorbid depression and anxiety. Poor mental health exacerbates the cost of the treatment and management of CNCs. CBT is recommended for the treatment of depression. However the application of CBT to individuals with CNCs may be limited by disease characteristics (e.g. mobility issues restricting therapy attendance and reducing engagement with behavioural activation, as well as difficulties challenging the veracity of disease-related negative thoughts that may reflect accurate appraisals). The objective of this review is to assess the clinical effectiveness of cognitive and behavioural interventions for depressive symptoms in individuals with non-acquired, medically explained CNCs.

DATA SOURCES

Searches of The Cochrane Controlled Trials Register, PubMed, and PsychINFO were conducted.

RESULTS

All studies suggested that CBT is an effective treatment for depression comorbid to CNCs, however when CBT was compared to an active therapy control condition, between group differences were unstable.

CONCLUSION

CBT has promise for the treatment for depression in such conditions; however treatment protocols and outcome measures should be adapted for this population. Future trials should control for non-specific effects of therapy and, as much as possible, introduce blinding into methodologies.

Is EEG a useful test in adult psychiatry?

BACKGROUND

We present a brief overview of the use of EEG in psychiatry, with particular emphasis on differential diagnosis examination in case of acute psychiatric conditions.

METHOD

The article is based on a literature search in PubMed and the authors' own collections of articles and personal experience.

RESULTS

Onset of epilepsy, encephalitis or other cerebral diseases may be accompanied by psychiatric or cognitive symptoms. Slow EEG activity may be an unspecific sign of cerebral disease. Psychiatric patients are also at an increased risk of epilepsy. In case of seizure symptoms such as convulsions or conditions with rapid changes in affective states, epileptiform activity during EEG is a specific sign of epileptic aetiology or comorbidity. Quantitative frequency analysis (QEEG) is useful for research purposes and in exceptional cases also in a clinical context. No QEEG method has as yet become accepted as providing reliable, independent markers for psychiatric disease or treatment response.

INTERPRETATION

EEG should be undertaken in case of newly occurring psychoses and for conditions with a fluctuating or progradiating loss of cognitive function. Adult psychiatric patients with seizure symptoms or rapid changes in affective states should also be referred to EEG.

Psychiatric comorbidity in patients with pharmacoresistant focal epilepsy and psychiatric outcome after epilepsy surgery

There are only a few studies in which both preoperative psychiatric comorbidity in pharmacoresistant focal epilepsy and its outcome after epilepsy surgery have been investigated. In this study, 144 patients evaluated for epilepsy surgery received psychiatric examination, 84 proceeding to intervention were reassessed postoperatively. Preoperatively, 60% met criteria for ICD-10- or epilepsy-specific psychiatric diagnosis. Twenty-seven percent, predominantly female, suffered from dysphoric disorder (DD) associated with temporal epileptogenic foci. Prevalence of DD correlated with complex partial seizure frequency and presence of ictal fear suggesting limbic-cortical dysregulation. Psychotic syndromes were linked to a history of febrile convulsions and left-sided temporomesial epileptogenic foci. High seizure frequency and early epilepsy onset predisposed to the development of personality disorders. Postoperative assessment revealed 18% of patients with "de novo" interictal affective disorders after surgery. Symptoms in 48% of patients with preoperative affective syndromes and 60% of patients with DD remitted after surgery. Seizure freedom and improved psychosocial status predicted remission of preoperative psychopathology.

Obsessive-compulsive disorder in chronic epilepsy

There is a long-recognized association between obsessive-compulsive disorder (OCD) and chronic epilepsy, most notably refractory temporal lobe epilepsy (TLE). The literature documents this association with case reports, patient series, and some larger controlled studies that reveal that almost a quarter of patients with TLE exhibit OCD features, which may go unrecognized. Obsession features with ordering, symmetry, exactness, handwashing, and religiosity occur more often in persons with right- or left-sided epileptic foci than in those with idiopathic generalized epilepsies or controls. Neurobiological and social factors suggest abnormalities of the frontal-thalamic-pallidal-striatal-anterior cingulate-frontal circuits stemming from the observation that certain diseases, damage, or surgery along these circuits may produce or, conversely, reduce OCD in TLE. This review explores the literature on case reports, case series, and larger retrospective controlled studies and looks at the associations of epilepsy with OCD. Contemporary speculation on the theoretical neurobiological underpinnings provides some basis on how and where to direct treatment. Invasive deep brain stimulation has triggered recent controversy on newer treatment modalities.

Tolerability of atomoxetine for treatment of pediatric attention-deficit/hyperactivity disorder in the context of epilepsy

To examine atomoxetine's tolerability in patients with epilepsy, we reviewed medical records of all patients with epilepsy who were treated with atomoxetine in a tertiary care pediatric psychopharmacology practice. Twenty-seven patients (10.1 ± 4.2 years, 63% male) with an average seizure frequency at baseline of 7 ± 24 per month (median: 0, range: 0-90) were found. Symptoms of attention-deficit/hyperactivity disorder in twenty-five patients (92.5%) had previously not responded to stimulants. Atomoxetine, average dose 35.2 ± 24.4 mg, was given for a median of 26 weeks (range: 4-141). Seventeen patients (63%) discontinued atomoxetine due to: inadequate response (n=7, 26%), worsening behavior such as increased irritability/activation (n = 7, 26%), nonadherence (n=1, 4%), emerging psychotic-like symptoms (n=1, 4%), and appetite decrease and tremor (n=1, 4%). There were no discontinuations because of seizure exacerbation. Atomoxetine dose, epilepsy etiology, seizure type, and comorbid psychiatric disorders did not predict discontinuation. No safety problems of sufficient magnitude to preclude prospective studies of atomoxetine in children with epilepsy were found.

Epilepsy and obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) has long been associated with epilepsy. The link with temporal lobe (usually refractory) epilepsy (TLE) is particularly prominent. Of TLE patients, 10% to 22% of patients may have OCD, often underdiagnosed in the outpatient clinic. Data on the links include case reports, case series, and controlled studies. Three larger, controlled studies in TLE patients, using comprehensive epilepsy and OCD classifications, in aggregate, have noted the obsessive qualities of washing, symmetry/exactness, and ordering, with a greater preoccupation with certain aspects of religion, compared with controls or patients with idiopathic generalized epilepsy. TLE foci may be either left- or right-sided. Social and neurobiological factors are involved in OCD in TLE. The neurobiology implicates a pathophysiological or structural impairment of the orbitofrontal-thalamic, and frontothalamic-pallidal-striatal-anterior cingulate-frontal circuits. Discrete anatomic lesions in these pathways, or their surgical removal, may induce (or conversely) improve OCD in TLE patients.

A comparative study of obsessive-compulsive disorder and other psychiatric comorbidities in patients with temporal lobe epilepsy and idiopathic generalized epilepsy

Our aim was to assess the associations of temporal lobe epilepsy (TLE) and idiopathic generalized epilepsy (IGE) with comorbid psychiatric conditions, especially obsessive-compulsive disorder (OCD), in a comparative design. We evaluated 29 patients with TLE, 27 patients with IGE, and 30 healthy controls. The Structured Clinical Interview for DSM-IV (SCID), Yale-Brown Obsessive Compulsive Scale (Y-BOCS) Symptom Checklist, and Beck Depression Inventory (BDI) were administered. Among patients with TLE, 75.9%, and among patients with IGE, 48.1% had at least one Axis I psychiatric disorder. Clinically meaningful obsessive-compulsive symptoms (CM-OCS) were noted in 10 patients with TLE and in 3 patients with IGE, and this difference was statistically significant (P<0.05). CM-OCS were present in 9 of 18 patients with left-sided TLE, but in only 1 of 11 patients with right-sided TLE. Higher comorbidity in TLE suggests that involvement of the temporal lobe may play a role in the development of specific psychopathological syndromes.

Ion channel functional candidate genes in multigenic neuropsychiatric disease

Scores of monogenic Mendelian ion channel diseases serve to anchor the pathophysiology of the channelopathies, but there are also now clear examples of environmental, pharmacogenetic, and acquired channelopathy mechanisms. The cardinal feature of heritable ion channel disease is a periodic disturbance of rhythmic function in constitutionally hyperexcitable tissue. While the complexity of neuroanatomy obscures functional analysis of mutations causing monogenic seizure, ataxia, or migraine syndromes, extrapolation from the cardiac (Long QT [LQT]) and muscle (Periodic Paralysis) channelopathy syndromes provides a simplified predictive framework of molecular pathology: electrically stabilizing potassium ion (K(+)) and chloride ion (Cl(-)) channels, likely having lesions that diminish their current, and excitatory Na(+) channels, likely having gain-of-function lesions. The voltage-gated calcium channel gene family that contains CACNA1C, the newest LQT locus, causing Timothy Syndrome with a phenotype including autism, has proven to be particularly informative for its members' ability to tie the various central nervous system (CNS) phenotypes together in an interpretable fashion, now including direct extension to the classically multigenic neuropsychiatric phenotypes. Features of a promising ion channel candidate gene arise from its broad locus, gene family, nature of alleles, physiology and pharmacology, tissue expression profile, and phenotype in model organisms. KCNN3 is explored as a paradigm to consider.

No seizure exacerbation from risperidone in youth with comorbid epilepsy and psychiatric disorders: a case series

OBJECTIVE

The aim of this study was to study risperidone use in pediatric patients with comorbid epilepsy and psychiatric disorders.

METHOD

We retrospectively reviewed the outpatient psychopharmacology medical records of patients with epilepsy, aged 19 and younger, who received risperidone for psychiatric disorders.

RESULTS

Twenty-one (21) youths (mean age, 12.0 +/- 4.2 years) met our criteria for review. Mean risperidone dosage was 2.4 +/- 3.5 mg/day. Target symptoms included severe aggression, severe agitation, psychosis, and self-injurious behavior. Diagnoses included attention-deficit hyperactivity disorder (ADHD), learning disorder, and impulse control disorder. Seizure type was partial complex in 12 patients, generalized in 6 patients, neonatal in 1 patient, myoclonic in 1 patient, and unclassified in 1 patient. The average number of previous psychotropic trials was 3.5 +/- 3.0. Using a definition of response of a Clinical Global Impressions (CGI) improvement score of 2 or less, 15 patients (71%) were considered responders. Adverse effects were none to slight in 16 patients, moderate in 4 patients, and severe in 1 patient. Seizures did not worsen in any patient.

CONCLUSIONS

Risperidone was associated with a clinically significant global improvement, without seizure exacerbation in youths with epilepsy and psychiatric disorders. Despite the limitations of the study design, the 71% responder rate is noteworthy in this treatment-refractory group.

Psychiatric comorbidity in patients with epilepsy: implications for diagnosis and treatment

Psychiatric disorders frequently occur in patients with epilepsy but the diagnosis is frequently missed and therapeutic opportunities are often lost. These comorbidities assume greater importance as epidemiological data show their frequent association with impaired function and quality of life, and advances in neurobiology better define their pathophysiological relationship and therapies. Epilepsy presents a model for understanding psychiatric illness. Deciphering the role of different biological and environmental risk factors may help identify high-risk patients and allow for early intervention. Antiepileptic drugs are frequently used to manage psychiatric syndromes although the mechanisms of their psychotropic action remain uncertain. As recognition and treatment of comorbid psychiatric disorders in epilepsy remain suboptimal, we need to increase the awareness of physicians, patients, their caregivers, and the health care system. Better recognition will help to develop and implement appropriate diagnostic and treatment programs, and improve functional outcomes and quality of life in people with epilepsy.