A prospective study of anxiety with respect to seizure outcome after epilepsy surgery

Thirteen-year follow-up of long-term treated psychotic disorder: personality aspects

OBJECTIVE

Personality is an aspect that can affect the symptoms and social function in individuals with psychotic disorders. Several studies have investigated personality in schizophrenia and other long-term psychotic disorders. No study has examined the stability of personality traits exceeding five years in patients with schizophrenia and related disorders. The aim of this study was to investigate the stability of personality traits over a 13-year period among patients with schizophrenia and related disorders and healthy individuals and to evaluate case-control differences.

METHODS

At three occasions during a 13-year period patients with schizophrenia and related disorders (n = 28) and healthy individuals (n = 57) completed Swedish universities Scales of Personality (SSP). Mean-level change and case-control differences were investigated for all the individuals using within- and between-subject analyses, respectively. Analyses were performed on three occasions for all 13 subscales and the three overall factors of SSP. Also, correlations, means, and SDs were calculated.

RESULTS

Tests of within-subject correlations showed differences in two subscales: Lack of Assertiveness, which were influenced by age, and Physical Trait Aggression, where patients' ratings were stable, whereas controls rated themselves less aggressive at a higher age. Between-subjects correlations showed differences regarding diagnosis, time, age, gender, or age × gender in nine of the 13 subscales as well as in factor Neuroticism.

CONCLUSION

Long-term follow-up showed generally high stability of personality traits measured with SSP. Between-subject analyses over the 13 years showed that patients differed compared to controls for the SSP factor Neuroticism as well as the subscale Detachment, which is in accordance with previous studies within this population.

Temporal Lobectomy: Does It Worsen or Improve Presurgical Psychiatric Disorders?

Temporal lobe epilepsy (TLE) is the type of epilepsy most frequently associated with psychiatric morbidity. Respective surgery for focal epilepsy remains the preferred treatment for medically resistant epilepsy. The aim of this chapter is to review what happens with psychiatric disorders once patients have undergone surgery.Early studies demonstrated a post-surgical increase in the incidence rates of anxiety and depressive disorders, while recent studies found that the prevalence of depression and anxiety decreased 12 months after surgery. In spite of this improvement, de novo anxiety and depressive or psychotic cases can be seen. In particular, de novo psychosis ranges from 1% to 14%, with risk factors including bilateral temporal damage, tumors rather than mesial temporal sclerosis, and seizures emerging after surgery again.Personality changes after temporal lobectomy are yet to be established, but decline in schizotypal behavior and neuroticism is the most replicated so far.In children's studies surgery resolved 16% of the participants' psychiatric problems, while 12% presented a de novo psychiatric diagnosis, but further, more conclusive results are needed.The main limitations of these studies are the inconsistent systematic post-surgical psychiatric evaluations, the small sample sizes of case series, the short follow-up post-surgical periods, and the small number of controlled studies.A psychiatric assessment should be conducted before surgery, and most of all, patients with a psychiatric history should be followed after surgery.

Psychiatric outcome of temporal lobe epilepsy surgery: A prospective, 2-year follow-up study

OBJECTIVE

We performed a prospective, longitudinal, 2-year follow-up study to clarify psychiatric courses and outcomes after temporal lobe epilepsy surgery.

METHODS

We assessed 141 patients (68 men, 73 women) aged 16 or older with structured interviews and psychiatric rating scales before surgery and 3 months, 1 year, and 2 years afterward.

RESULTS

Fifty-two patients (36.9%) had a psychiatric condition before surgery or during the follow-up period or both. The number of patients with a psychiatric condition decreased from 31 (22.0%) before surgery to 14 (9.9%) at 2 years. On the basis of our results, we defined 5 courses of psychiatric conditions: course 0, no psychopathology (n = 89, 63.1%); course 1, remission or resolution of a presurgical psychiatric condition after surgery (n = 19, 13.5%); course 2, new onset, transient psychiatric condition after surgery (n = 19, 13.5%); course 3, new onset, persistent psychiatric condition after surgery (n = 2, 1.4%); and course 4, chronic psychiatric condition before and after surgery (n = 12, 8.5%). In 14/25 (56.0%) patients with a mood or anxiety disorder before surgery, the condition remitted or resolved after surgery (course 1). Eighteen of 110 patients (16.4%) without any psychopathology before surgery developed mood or anxiety disorders afterward, including major depressive disorder in 13 patients (courses 2 and 3); in more than half of these patients, the disorder manifested within 1 year. More patients with a past history of psychiatric conditions were found in course 2 than in course 0. The duration of epilepsy was longer in course 4 than in course 0, and age at epilepsy onset was lower in course 4 than in course 0.

SIGNIFICANCE

Most patients with a psychiatric condition show a favorable outcome 2 years after surgery; however, some show a transient worsening or new onset of psychiatric conditions, in particular depression.

Psychiatric disorders in patients with resistant temporal lobe epilepsy two years after undergoing elective surgery. A longitudinal study

PURPOSE

Psychiatric morbidity in temporal lobe epilepsy (TLE) is frequent and negatively affects patients' life quality. Surgery is the procedure of choice when treating seizures, although the effects on psychiatric disorders remain unclear. We evaluate the effect of surgery on psychiatric disorders in patients with TLE two years after the intervention, to then shed light on how these are related to anxiety and depression symptoms, and Interictal Dysphoric Disorder (IDD).

METHODS

We included data from 65 patients with TLE whose psychiatric evaluations were performed according to DSM-IV criteria. Anxiety and depression symptoms were assessed using the Hospital Anxiety and Depression Scale (HADS) test.

RESULTS

At 2-year follow-up, anxiety and depressive disorders decreased, and psychotic disorders augmented without statistical significance. Baseline psychiatric disorders predisposed to psychiatric pathology at 2-year follow-up and did not correlate with epilepsy outcome after surgery. Postoperative psychiatric disorders correlated with the seizure incidence two years after the intervention, suggesting that epilepsy and psychiatric disorders were associated in processes such as surgery. De novo psychiatric disorders represented 52% of postoperative psychiatric pathology, 62% being psychotic disorders. De novo psychiatric disorders became more frequent from the first year of surgery, occurring mainly in patients free of seizures. The HADS test scores and IDD correlated with psychiatric disorders at 2-year follow-up.

CONCLUSIONS

Baseline psychiatric disorders did not influence surgery outcome, but correlated with psychiatric disorders' prevalence two years after surgery. Despite not finding statistical significance, surgery reduced the prevalence of psychiatric disorders, and de novo psychiatric disorders were associated with an improvement in the epilepsy course at 2-year follow-up.

Anxiety disorders in predominantly African American and Caribbean American adults with intractable epilepsy: The role of perceived epilepsy stigma

INTRODUCTION

Anxiety disproportionately affects people with epilepsy (PWE) and leads to poor outcomes. Yet, risk factors are not well understood especially among underserved groups. This cross-sectional study aimed to identify epilepsy-specific predictors of anxiety disorders in predominantly African American and Caribbean American PWE.

MATERIALS AND METHODS

The prevalence of anxiety disorders was established via diagnostic interview (Mini-International Neuropsychiatric Interview (MINI)). We identified the extent to which aspects of seizure burden (seizure frequency, seizure severity, convulsive vs. nonconvulsive seizures), seizure worry, and perceived epilepsy stigma were associated with anxiety disorder diagnosis. Finally, logistic regression assessed the overall and independent contributions of significant risk factors.

RESULTS

There were 60 participants (62% women, 52% African American, 27% Caribbean American, 20% Hispanic/Latino) with an average of 2 seizures per month. Nearly half of the sample (43%) had ≥1 anxiety disorder, with 62% of affected individuals qualifying for agoraphobia. Those with anxiety disorders tended to have convulsive seizures (p = 0.037) and endorsed greater seizure worry (p = 0.012), more general symptoms of anxiety (p = 0.005), and worse perceived epilepsy stigma (p = 0.003). Logistic regression accounted for 28% to 37.6% of the variance in anxiety disorder diagnostic status and correctly classified 73% of cases; however, only perceived epilepsy stigma made a unique contribution.

CONCLUSIONS

Anxiety disorders were prevalent in these predominantly African American and Caribbean American PWE. Epilepsy-specific risk factors included convulsive seizures, seizure worry, and perceived epilepsy stigma. Interventions aimed at treating anxiety disorders in diverse PWE may especially benefit from targeting stigma beliefs.

A right amygdalohippocampectomy: A diagnostic challenge

OBJECTIVE

Amygdalohippocampectomy (AHE) is the resective surgery for medically intractable mesial temporal lobe epilepsy. To date no study has investigated a wide range of neuropsychiatric symptoms in right AHE outpatients.

PATIENTS AND METHODS

Three patients with right AHE participated in this study. The control group are patients with cognitive complaints with no history of epilepsy or neurological impairment and no structural abnormalities on the MRI/CT. We expected no difference in verbal memory compared to the controls. Concerning affective Theory of Mind (ToM) we expect a difference between controls and AHE patients. In terms of behavior it is expected that coping and behavioral questionnaires do not significantly differ between AHE and controls, but that proxies of AHE patients do report more behavioral/psychiatric symptoms.

RESULTS

No significant difference was found between groups concerning the cognitive functions. For affective ToM we did find a significant difference (p=0.044). A significant difference for the use of more reassuring thoughts (p=0.006) and a trend for less passive reactions on the coping questionnaire, suggesting an 'active coping style'. Overall, AHE patients report fewer problems the self- reported questionnaires. Proxies of the AHE patients reported a trend for more behavioral disinhibition compared to proxy ratings of the control group.

CONCLUSION

Right AHE patients underestimate their behavioral and emotional changes due to self-awareness deficits. Ratings of significant others are of immense importance for the detection of psychiatric and behavioral problems. Lesions in the amygdala- orbitofrontal cortex connection disrupt the emotional network, which might explain our results.

Health-related quality of life, mood, and patient satisfaction after epilepsy surgery in Sweden--a prospective controlled observational study

Objective

To evaluate health-related quality of life (HRQOL), mood, and patient satisfaction in epilepsy surgery candidates before and 2 years after epilepsy surgery or presurgical investigation.

Methods

In this prospective study of 141 patients, 96 underwent surgery and 45 did not. Questionnaires at baseline and at 2-year follow-up included the generic 36-item Short Form Health Survey (SF-36), the Hospital Anxiety and Depression scale (HAD), and operated patients answered patient satisfaction questions. SF-36 scores were compared with scores from a matched sample from the Swedish norm population. Numbers were calculated of patients achieving a minimum important change (MIC) in the SF-36 Physical Composite Summary (PCS) and Mental Composite Summary (MCS).

Results

At baseline, patients had significantly lower values than the norm on all SF-36 domains. At follow-up, operated patients were divided into seizure-free (International League Against Epilepsy [ILAE] class 1 and 2, n = 53) or with continued seizures (n = 43). No differences in baseline HAD or SF-36 values were found between these groups. Seizure-free patients reached the same levels as the norm in all SF-36 domains except Social Function. Operated patients with continued seizures and nonoperated patients had unchanged scores. Fifty-one percent of seizure-free patients had an improvement reaching MIC for PCS and 45% for MCS. Corresponding results for patients with continued seizures were 28% in PCS and 28% in MCS, for nonoperated 33% in PCS and 29% in MCS. HAD anxiety scores improved significantly in only the seizure-free patients. Of all operated patients, 80% were satisfied with having had surgery and 86% considered that they had benefited, whereas 20% thought that surgery caused some harm.

Significance

In patients who were seizure-free after epilepsy surgery HRQOL normalized and anxiety decreased. Operated patients overwhelmingly considered epilepsy surgery to be beneficial. Nonetheless, only about half of the seizure-free patients achieved important HRQOL improvements, suggesting that seizure freedom does not in and of itself guarantee improved patient well-being.

Predicting and preventing psychopathology following temporal lobe epilepsy surgery

Less than 3% of temporal lobe epilepsy (TLE) surgical outcome studies have investigated the psychiatric sequelae and morbidity associated with surgery. This is disproportionate to the extent of the problem. Variable prevalence rates have been reported for post-surgical depression, anxiety, and interictal psychosis. Until recently, very few studies distinguished de novo postoperative presentations from pre-existing conditions, making it difficult to accurately assess the impact of TLE surgery on psychiatric morbidity. Predictors of de novo postoperative presentations have proved elusive. This current review summarizes the findings from a systematic literature review of the psychiatric morbidity associated with TLE surgery including newly published follow-up data from our own series of 280 surgical patients. A framework for future research, possible pathophysiological mechanisms, and translational models are also discussed.

Psychosocial difficulties in people with epilepsy: a systematic review of literature from 2005 until 2010

The aims of this paper are to identify factors that influence the psychosocial difficulties (PSDs) that persons with epilepsy experience in their everyday life, to describe their onset and the way they evolve over time, and to analyze the determinants of changes over time and other related variables. Electronic databases were searched for studies published in English between January 2005 and May 2010, and information from thirteen studies was extracted. The most frequent PSDs found in people with epilepsy were depressive symptoms, memory functions, quality of life, anxiety, stigma, locus of control, cognitive functions in general, and emotional functions in general. It can be stated that patients' life areas are affected by cognitive, emotional, and psychological problems. However, the majority of studies focus on isolated PSDs or on the effects of a specific determinant in the course of epilepsy, leaving some gaps that could encourage further research.

A longitudinal study of psychological features in patients before and two years after epilepsy surgery

This study aimed at investigating psychological features before and two years after epilepsy surgery. Fifty patients, 39 with temporal lobe epilepsy (TLE) and 11 with frontal lobe epilepsy (FLE), were assessed at baseline and two years postoperatively with the Karolinska Scales of Personality (KSP). Baseline group level outcome was normal while individual level analyses delineated some mild to moderate degrees of psychological problems exceeding the normal range in subsets of patients. Features of hostility characterized half of the FLE and one-fourth of the TLE patients. Above 1/3 in each group had dependency features. About 1/3 of the TLE patients suffered from psychasthenia. In conclusion, even though group levels were normal, several patients had psychological problems. The main longitudinal result was that the personality features were stable and did not change after epilepsy surgery.

Life adjustment after surgical treatment for temporal lobe epilepsy

OBJECTIVE: The purpose of this study was to evaluate the patients' life adjustment after epilepsy surgery, through instruments of quality of life (QoL), anxiety, depression, preoperative expectations and postoperative life changing. METHODS: Thirty-six adults who underwent temporal lobe epilepsy surgery were interviewed before surgery, and 6 and 12 months after surgery. RESULTS: For all patients, epilepsy surgery gave rise to an evolving process of postoperative adjustment, what means that they were satisfied with surgery results, and that their expectations were reached. The improvement was seen in their QoL (p=0.004), anxiety (p=0.019) and depression (p=0.001), which was associated to their perception of positive life changing. The inexistence of depressive and anxiety symptoms and the good QoL after surgery predicted the perception of positive life changing. This study could predict a total of 56.5% of aspects involved in the perception of positive life changing after epilepsy surgery, what seems that other variables may be involved in this process. The patients' status before surgery (expectations, QoL, anxiety, depression and seizures frequency) did not predict the life satisfaction after surgery, what means that when patients evaluate their actual lives they do it looking for daily aspects and do not tend to compare to their lives before surgery. CONCLUSION: The findings of the present study have implications for the evaluation of life adjustment postsurgery, calling attention to measures of preoperative expectations, anxiety, depression and QoL. The strength of these contributions highlights the importance of registering the patients' feelings and opinions during the presurgical evaluation and may help the health providers to understand the aspects necessary to improve the patients' quality of life.

Outcomes of epilepsy surgery in adults and children

Surgery is widely accepted as an effective therapy for selected individuals with medically refractory epilepsy. Numerous studies in the past 20 years have reported seizure freedom for at least 1 year in 53-84% of patients after anteromesial temporal lobe resections for mesial temporal lobe sclerosis, in 66-100% of patients with dual pathology, in 36-76% of patients with localised neocortical epilepsy, and in 43-79% of patients after hemispherectomies. Reported rates for non-resective surgery have been less impressive in terms of seizure freedom; however, the benefit is more apparent when reported in terms of significant seizure reductions. In this Review, we consider the outcomes of surgery in adults and children with epilepsy and review studies of neurological and cognitive sequelae, psychiatric and behavioural outcomes, and overall health-related quality of life.

Psychiatric outcome of surgery for temporal lobe epilepsy and presurgical considerations

In recent years, surgery has become a treatment option for some patients with intractable epilepsy, particularly those with temporal lobe epilepsy. Psychiatric disturbances may complicate the postsurgical outcome in some patients and de novo psychiatric symptoms have been reported. In many but not all epilepsy surgical centres, a psychiatric assessment is included as part of the presurgical evaluation of potential candidates for surgery. This review indicates that affective disorders, namely, depression and anxiety, and psychosis are the most frequently reported postsurgical psychiatric disturbances. Whilst there are no absolute psychiatric contraindications to surgery, certain pre-existing psychiatric conditions may need careful consideration as there may be a risk of postsurgical psychiatric complications. Routine pre- and postsurgical psychiatric evaluations in patients undergoing epilepsy surgery are recommended. Clinicians involved in the care of surgical candidates should be aware of the possible psychiatric complications following surgery and ensure that the psychiatric risks are discussed with the patient and family.

Psychiatric disorders in temporal lobe epilepsy patients over the first year after surgical treatment

OBJECTIVE

To evaluate the psychiatric disorders over a 1-year period in a group of TLE patients who underwent surgery.

METHODS

Prospective, open study in a sample of 70 TLE patients. Psychiatric disorders' assessment was made before surgery, and at 1, 6 and 12 months after surgery, with the structured clinical diagnostic interview for DSM-IV axis I diagnoses (SCID). Presurgical psychiatric and neurological variables were compared with the outcomes of surgery and the course of psychiatric pathology over the follow-up through parametric and non-parametric tests.

RESULTS

Depression decreased from 17.2% before surgery to 4.3% at 12 months after surgery (chi(2)=5.41, d.f.=1, p=0.071), anxiety disorders decreased from 21.5% before surgery to 14.2% at 12 months after surgery (chi(2)=10.309, d.f.=1, p<0.005). Patients with no presurgical psychiatric condition had lower postsurgical rate of psychiatric disorders than those with psychiatric history (X(2)=9.87, gl=1, p< or =0.001), with psychiatric disorders in the presurgical evaluation (X(2)=12.02, gl=1, p< or =0.001), or with both conditions (chi(2)=15.28, d.f.=1, p<0.001). No association was found between psychiatric disorders and the outcomes after surgery. No association was found between the course of psychiatric disorders before and after surgery and neurological or neurosurgical variables.

CONCLUSIONS

Surgery in TLE patients does not worsen the global psychopathological status. Presurgical psychiatric morbidity was found to be related to the presence of psychiatric disorders after surgery. Specific psychiatric assessment should be made before and after surgery.

Memory, emotional and vocational impairments before and after anterior temporal lobectomy for complex partial seizures

PURPOSE

To assess the pre- and postsurgical frequency of memory, emotional, and vocational impairments in patients who underwent anterior temporal lobectomy (ATL), and to assess the relationship between emotional disturbance and memory abilities after ATL.

METHODS

Retrospective analysis of data was performed on 90 patients with medically intractable complex partial seizures who underwent ATL between 1981 and 2003. Patients were evaluated an average of 5 months before surgery and 11.3 months after surgery.

RESULTS

A moderate to high frequency of memory impairment (44.4%; verbal or nonverbal), emotional disturbance (38.9%) and unemployment (27.8%) existed in the same individuals both before and after surgery. There were small to moderate rates of new onset memory (18.9%), emotional (11.1%), and vocational (7.8%) difficulties after surgery often regardless of seizure control outcome. Patients who underwent left-ATL and had emotional disturbance after surgery had the lowest verbal memory test scores.

CONCLUSIONS

Results highlight the importance of taking into account emotional status when assessing memory abilities after ATL. Results replicate the finding of moderate to high frequencies of memory impairment, emotional disturbance, and unemployment both before and after ATL. Results provide support for the rationale that cognitive, psychiatric and vocational interventions are indicated to mitigate the problems that exist before and persist after ATL.

Anxiety in patients with epilepsy: systematic review and suggestions for clinical management

Up to 50 or 60% of patients with chronic epilepsy have various mood disorders including depression and anxiety. Whereas the relationship between epilepsy and depression has received much attention, less is known about anxiety disorders. It is now recognized that anxiety can have a profound influence on the quality of life of patients with epilepsy. The relationship between anxiety disorders and epilepsy is complex. It is necessary to distinguish between different manifestations of anxiety disorder: ictal, postictal, and interictal anxiety. Preexisting vulnerability factors, neurobiological factors, iatrogenic influences (antiepileptic drugs, epilepsy surgery), and psychosocial factors are all likely to play a role, but with considerable individual differences. Despite the high prevalence of anxiety disorders in patients with epilepsy, there are no systematic treatment studies or evidence-based guidelines for best treatment practice. Nevertheless, a practical approach based on the temporal relationship between anxiety and epileptic seizures allows clinicians to consider appropriate treatment strategies to reduce the psychiatric comorbidity in patients with epilepsy.