Pain as an old friend

The "burden of normality": concepts of adjustment after surgery for seizures

OBJECTIVES

To conceptualise the process of adjustment provoked by the sudden alleviation of chronic epilepsy by temporal lobectomy. On being rendered seizure free, the process of adjustment primarily depends on the patient's capacity to discard roles associated with chronic epilepsy and to learn to become well. This can involve a reconceptualisation of the patient's identity from chronically ill to "cured", and can give rise to a constellation of psychological, affective, behavioural, and sociological features characterised as the "burden of normality".

METHODS

This is a theoretical inquiry that documents the clinical phenomenology of the burden of normality by classifying its key psychological and psychosocial features. The model of adjustment is presented in the context of previous outcome research on surgery for seizures, providing a conceptual link between practice based rehabilitation measures of outcome and multidimensional constructs, such as health related quality of life.

RESULTS

The model represents a process oriented, theoretical framework for comprehensively measuring outcome after life changing medical interventions. It has implications for clinical practice, including the identification of preoperative predictors of outcome and informing appropriate management and rehabilitation of patients.

CONCLUSION

This model of outcome after temporal lobectomy may ultimately be applicable to the treatment of other chronic conditions.

Psychosocial difficulties and outcome after temporal lobectomy

One hundred fifteen consecutive patients in the Austin Hospital Comprehensive Epilepsy Program (Melbourne, Australia) were surveyed to document the psychosocial and rehabilitation difficulties after temporal lobectomy. During the follow-up period (mean 4 years) 3 patients died, 5 patients were lost to follow-up, and 107 patients with family and friends were interviewed. Eighty-four patients (78%) had been seizure-free for the year preceding the interview; 13 others had seizure reduction greater than 75%. Success in ablation or reduction in seizures correlated with the amount of postoperative gain, but in this series, analysis of work and dependency outcome did not emphasize areas of success. Although improvement in work and financial status, interpersonal relations and sexuality were all recorded, successful patients deemed that most advance had been made in the areas of newly acquired independence, enhanced career potential, and social freedom. Significant postoperative anxiety, especially after left temporal lobectomy, was noted, possibly explained by benzodiazepine antiepileptic drug (AED) discontinuation. Although 1 patient committed suicide, neither depression nor psychosis was common in the rehabilitation period, in contrast to results in previous series. Significant sociodomestic problems emerged from this survey, however: 35% of patients considered successes reported postoperative problems stemming from the necessity to restructure family dynamics; in 6%, this resulted in divorce. Moreover, 20% of patients and relatives reported significant behavioral problems in coping with the seizure-free lifestyle. Finally, the problems of the worsened situation after surgical failure indicated the counterproductive potential of ineffective lobectomy. These results indicate the necessity for a preoperative counseling program to prevent these problems.

Clinical evaluation of mild analgesics

1 Mild analgesics pose particular problems in evaluation because of difficulty in getting suitable patients, the frequent use of oral administration and their long-term use. 2 Despite their limitations it is possible to quantify both pain severity and pain relief using either 'pain scores' or 'visual analogues'. 3 A trained observer can add information in addition to the patient's interpretation of pain. 4 There are particular problems using crossover studies with analgesics and the sequential method of evaluating results is not as useful with mild analgesics as with more potent drugs. 5 Opinions differ as to the importance of dummy medication in the study of analgesic drugs; difficulties may arise from ethical as well as practical reasons. 6 In the overall evaluation of mild analgesics it is important to consider their long term side effects. 7 Access to a large number of patients with a constant pain of 6-8 h duration and a smaller number with long-term pain is the most important prerequisite in the evaluation of mild analgesic drugs.

Monosymptomatic hypochondriasis, abnormal illness behaviour and suicide

Two cases of chronic monosymptomatic psychogenic eye pain with abnormal illness behaviour are presented. Both failed to respond to a wide variety of treatments, and despite the accepted low suicidal risk in hypochondriasis both killed themselves. The origin, prognosis and therapy of such behaviour are discussed in this context.

Personality changes associated with reduction of pain

Of 113 patients treated in a 2-year period, for whom complete data were available, 29 who received surgery for pain relief were compared with 84 who did not, both groups receiving psychological treatment and rehabilitation. Using an analysis of covariance to eliminate pre-treatment differences, the surgery patients showed significantly greater reductions on the MMPI Hysteria and Hypomania scales, and on the invalidism scale of a Health Index, and this was associated with a significantly greater reduction of pain. These differences obtained despite a greater increase in activity levels by the non-surgery patients at the time of testing. The results support the hypothesis that the neuroticism associated with chronic pain is the result of it, and may be reversible when the pain is reduced or abolished.

Borderlands between neurology and psychiatry: observations in a neurological hospital

This article describes psychiatric liaison, in its clinical and teaching aspects, at the Montreal Neurological Institute. Referral patterns are illustrated by data on 200 neurological and neurosurgical patients referred for psychiatric consultation. Our total patient material of nearly 1000 such patients seen in consultation and a joint weekly teaching session provide the basis for comprehensive discussion of the borderlands between neurology and psychiatry. It is concluded that close collaboration between these two disciplines is advantageous to both, in terms of improved clinical training of residents, identification of promising areas for interdisciplinary research, and better overall patient care. These gains justify the development of such liaison in other centers.

Rostral leucotomy: a report on 240 cases personally followed up after 1 1/2 to 5 years

Cortical undercutting, as an alternative to standard leucotomy and to the major operation of topectomy, was devised by three surgeons independently. Scoville (1949) published his preliminary results soon after McKissock had begun to do rostral leucotomies. Both have continued to use this type of operation (Scoville et al., 1951; Scoville, 1954) but Ferey (1950), the third to develop a similar technique, was disappointed with the results and soon abandoned it (Ferey, 1953). McKissock (1951) reported the initial impressions of the results in 100 cases and by the end of 1952 had operated on 240 cases. During 1953–54, 1½ to 5 years after operation, I followed up these patients, visiting 175 of them in their homes, and 35 in hospital. Personal follow up was refused or for some reason impracticable in 17 cases, including 4 whose case notes had been destroyed; 13 others had died before the survey was made.

Partridge (1950) reported a follow up study of 300 cases operated on by the same surgeon by his “standard” technique (McKissock, 1943); he had the advantage, which I had not, of being able to see his patients before operation. I have had to work retrospectively, and the case notes available, whilst often excellent, had usually not been made with the idea that they would be needed for follow-up purposes. I have not, therefore, thought it right to draw more than broad conclusions from this study.