Psychogenic nonepileptic seizures

Caregiver burden in psychogenic non-epileptic seizures

OBJECTIVE

Caregiver burden in psychogenic non-epileptic seizures (PNES) is an important but understudied reality. The objective of this exploratory study was to quantify caregiver burden in PNES and to identify the patient and caregiver characteristics associated with it.

METHODS

PNES patients and their identified caregivers completed surveys about demographic, disease related and psychosocial characteristics during their Epilepsy Monitoring Unit (EMU) admission. Associations were evaluated using the Zarit Caregiver Burden Inventory (ZCBI) score as an independent variable and the patient and caregiver related characteristics as dependent variables.

RESULTS

43 patients and 28 caregivers were recruited. The patients were on average 36 years old, single women, unemployed, with some college education. They suffered from PNES on average for 8 years, having approximately 20 seizures per month, and were previously maintained on ≥ 2 antiseizure medications. Most caregivers were first degree relatives with a mean age of 43 years, married employed women of higher educational attainment, typically cohabitating with the patients. Caregiver burden was within the mild-moderate range (ZCBI mean score 28). The burden appeared higher in caregivers of male patients. Patient quality of life, depression and medication side effects were associated with that burden. Additionally, caregiver stigma, depression and anxiety emerged as potential contributors. In the multivariate analysis, patient quality of life and caregiver depression stood out as the most robust factors.

CONCLUSION

There is substantial caregiver burden in PNES. It is associated with both the patient and the caregiver psychosocial well-being in a reciprocal relationship.

A systematic study of stereotypy in epileptic seizures versus psychogenic seizure-like events

OBJECTIVE

The objective of this study was to quantify the features of stereotypy in epileptic seizures and compare it with that of stereotypy in psychogenic nonepileptic seizure-like events (PNES) confirmed by video-electroencephalography (VEEG) monitoring.

METHODS

Video-electroencephalography monitoring records of 20 patients with temporal lobe seizures (TLS) and 20 with PNES were retrospectively reviewed (n = 138 seizures, 48 TLS and 90 PNES). We analyzed the semiology of 59 behaviors of interest for their presence, duration, sequence, and continuity using quantified measures that were entered into statistical analysis.

RESULTS

We identified discontinuity as the parameter that was clearly distinct between PNES and epileptic TLS events: there were significantly more frequent pauses of behavior (i.e., "on-off" pattern) in PNES compared with TLS (P = 0.012). The frequency of pauses during an event was diagnostic of PNES events. For instance, the presence of 2 "pauses" during an episode determines a 69% probability of the seizure being nonepileptic. Moreover, PNES events had significantly greater duration (143 s) than TLS events (68 s) (excluding outliers, P = 0.002) and greater duration variability from one event to another in the same subject (P = 0.005).

SIGNIFICANCE

Our work provides the first quantified measure of behavioral semiology during epileptic and nonepileptic seizures and offers novel behavioral measures to differentiate them from each other.

Diagnosis of probable psychogenic nonepileptic seizures in the outpatient clinic: does gender matter?

Psychogenic nonepileptic seizures (PNESs) are paroxysmal events of altered behavior that outwardly resemble epilepsy but are caused by psychiatric disease. The diagnosis of probable PNESs can be made in the outpatient clinic prior to video-EEG monitoring by identification of specific PNES predictors and specific elements of seizure semiology from the clinical history. Since psychiatric disease may have distinct mechanisms between women and men, the objective of this study was to determine if gender-specific differences exist in PNES predictors and PNES semiology. Such differences could be used to optimize the accuracy of outpatient diagnosis of probable PNESs. Medical records of male and female patients with video-EEG diagnosis of definite PNESs were retrospectively reviewed for occurrence of PNES predictors. In addition, PNES semiology was analyzed de novo from video-EEG records and categorized into previously established semiology clusters. Eighty-six patients were included in the analysis (59 women and 27 men). We found significantly lower rates of reported physical and sexual abuse, lower rates of previous psychiatric diagnosis, and lower rates of chronic pain in male patients with no significant differences in rates of other PNES predictors. Furthermore, we found no difference in PNES semiology between men and women, with both groups experiencing similar rates of major motor, minor motor, and nonmotor semiology. In conclusion, our results lend support to the idea that distinct risk factor criteria but similar semiology criteria should be used for the diagnosis of probable PNESs in the outpatient clinic in men and women.

Clinical profile of psychogenic non-epileptic seizures in adults: A study of 63 cases

AIMS

To evaluate clinical profile and short-term outcome of psychogenic non-epileptic seizures (PNES) in Indian adult population.

SETTING AND DESIGN

A prospective observational study, conducted at tertiary teaching institute at New Delhi.

MATERIALS AND METHODS

Sixty-three patients with confirmed PNES were enrolled. The diagnosis was based on witnessing the event during video-electroencephalography (Video-EEG) monitoring. A detailed clinical evaluation was done including evaluation for coexistent anxiety or depressive disorders. Patients were divided into two groups on the basis of excessive or paucity of movements during PNES attacks. Patients were followed-up to 12 months for their PNES frequency.

STATISTICAL ANALYSIS

Means and standard deviations were calculated for continuous variables. Chi-square and Students t-test were used to compare categorical and continuous variables respectively.

RESULTS

The mean age at onset of PNES was 25.44 years; with F:M ratio of 9.5:1. Coexistent epilepsy was present in 13 (20.63%) cases. Twenty-two patients (44%) with only PNES (n = 50) had received antiepileptic drugs. Out of 63 patients of PNES 24 (38.1%) had predominant motor phenomenon, whereas 39 (61.9%) had limp attacks. The common features observed were pre-ictal headache, ictal eye closure, jaw clenching, resistant behavior, ictal weeping, ictal vocalization, and unresponsiveness during episodes. Comorbid anxiety and depressive disorders was seen in 62.3% and 90.16% patients, respectively. Short-term (6-12 months) outcome of 45 patients was good (seizure freedom in 46.66% and >50% improvement in 24.44% cases).

CONCLUSION

PNES is common, but frequently misdiagnosed and treated as epileptic seizures. A high index of suspicion is required for an early diagnosis. Proper disclosure of diagnosis and management of the psychiatric comorbidities can improve their outcome.

LIMITATION

Limited sample size and change in seizures frequency as the only parameter for the assessment of the outcome are the two major limitations of our study.

Impact of family functioning on quality of life in patients with psychogenic nonepileptic seizures versus epilepsy

PURPOSE

To evaluate different contributions of aspects of family functioning (FF) on health-related quality of life (HRQOL) in patients with psychogenic nonepileptic seizures (PNES) versus epileptic seizures (ES).

METHODS

Forty-five participants with PNES and 32 with ES completed self-report measures of FF (Family Assessment Device; FAD), HRQOL (Quality of Life in Epilepsy-31), and depression (Beck Depression Inventory-II; BDI-II). The FAD is a self-report questionnaire that assesses FF along six dimensions and general functioning. Regression analyses were used to evaluate the contribution of FF to HRQOL above and beyond the effects of disease severity and depression.

KEY FINDINGS

Mean Family General Functioning fell in the unhealthy range in participants with ES or PNES. On further analysis, male participants in each group endorsed unhealthy levels of FF compared to female participants. Patients with PNES reported poorer HRQOL and greater depressive symptoms compared to ES participants; there were no gender differences in HRQOL. Regression analyses indicated that the FAD Roles subscale predicted reduced HRQOL in patients with PNES after controlling for illness duration, seizure frequency, and depression. After controlling for the same factors, Communication and Affective Involvement subscales scores predicted HRQOL in ES participants.

SIGNIFICANCE

Family dysfunction was reported in both ES and PNES participants, but greater family dysfunction was experienced by male participants in both groups. Aspects of FF predicted HRQOL in patients with PNES and ES differentially. FF may be an important treatment target to enhance coping in these groups, although the treatments may need to target different aspects of FF in PNES versus ES.

Pseudonarcolepsy in an 11-year-old boy

Narcolepsy is a common disorder with a prevalence of 0.56/1000. Patients present with a classic tetrad of excessive daytime sleepiness, cataplexy, sleep paralysis and hypnagogic hallucinations, which is seen only rarely in children. The term ;narcolepsy' is taken from Greek and means ;seized by somnolence'; it was first described in 1880 by Gelineau. This article is a case study of an 11-year-old male with pseudonarcolepsy. He presented to accident and emergency with episodes of falling asleep at inappropriate and unexpected times, often falling to the floor. Pseudonarcolepsy is a term coined to describe the phenomenon in which a patient presents with the symptoms and signs of narcolepsy, but the origin is psychogenic. Differential diagnosis, investigation and possible aetiology are discussed, along with treatment and outcome.

Accuracy of Clinical Neuropsychological Versus Statistical Prediction in the Classification of Seizure types

Many studies have reported on the pattern of neuropsychological test performance across varied seizure diagnosis populations. Far fewer studies have evaluated the accuracy of the clinical neuropsychologist in formulating an impression of the seizure diagnosis based on results of neuropsychological assessment, or compared the accuracy of clinical neuropsychological judgment to results of statistical prediction. Accuracy of clinical neuropsychological versus statistical prediction was investigated in four seizure classification scenarios. While both methods outperformed chance, accuracy of clinical neuropsychological classification was either equivalent or superior to statistical prediction. Results support the utility and validity of clinical neuropsychological judgment in epilepsy treatment settings.

Challenging the established diagnosis in psychiatric practice: is it worth it?

A major source of clinical errors is inaccurate diagnosis. The authors stress the importance of a thorough work-up in establishing a reliable diagnosis and the need to challenge and correct erroneous diagnoses to avoid inadequate response, reduced adherence to treatment, medication errors, increased healthcare costs, unnecessary hospitalization, and other adverse outcomes. Four case reports are presented to illustrate common sources of psychiatric misdiagnosis: effects of switching several psychotropic agents simultaneously, confounding effects of systemic illness and/or substance abuse, poor communication among clinicians and between clinicians and patients, and excessive reliance on the expertise of specialists. In reviewing the cases, the authors focus on "red flags," such as lack of response to the current medication regimen despite adherence to treatment, that may be helpful in identifying diagnostic errors.

Prevalence of pseudoneurologic conversion disorder in an urban community in Manisa, Turkey

BACKGROUND

There is not a wide agreement upon rate of conversion disorder within Turkish population. The aim of this study was to determine the prevalence of conversion disorder with pseudoneurological symptoms or deficits and related risk factors in a city.

METHOD

In total, 1,086 people, aged 15-65 years old, were selected from the city of Manisa, Turkey to take part in the study. We applied sociodemographic and health information questionnaires and the Composite International Diagnostic Interview (CIDI) Somatization Subscales to the samples.

RESULTS

The likelihood that an individual might have conversion disorder with pseudoneurological symptoms or deficits was found to be 5.6% (n = 61). The prevalence of conversion disorder with pseudoneurological symptoms or deficits was significantly higher among women (p < 0.0001), 15-24 year old women (p = 0.011) and 25-34 year old women (p = 0.003), people who live as squatters (p = 0.03), those with a history of psychiatric disorder (p < 0.0001) and those having a mother with a psychiatric disorder (p = 0.04).

CONCLUSION

This study has shown the conversion disorder with pseudoneurological symptoms or deficits is inadequately frequent in the population.

Confrontation naming in individuals with temporal lobe epilepsy: a quantitative analysis of paraphasic error subtypes

Although confrontation naming deficits have been observed in dominant temporal lobe epilepsy (DTLE), the relative contribution of impoverished phonologic word retrieval and/or semantic knowledge remains unclear. Analysis of verbal-semantic, phonemic-literal, and combination paraphasias produced during confrontation naming by participants with seizure disorders (52 DTLE; 47 nondominant temporal lobe epilepsy [NDTLE]; 54 psychogenic nonepileptic seizures [PNES]) indicated that the frequency of: (a) verbal-semantic paraphasias was similar across groups, (b) phonemic-literal paraphasias was highest in DTLE, and (c) combination paraphasias was lowest in PNES. Confrontation naming ability was most strongly related to phonemic-literal paraphasia frequency in DTLE and to verbal IQ in both NDTLE and PNES. Greater confrontation naming deficits in DTLE may be attributed to impairments in phonological processing.

Characteristics of male veterans with psychogenic nonepileptic seizures

PURPOSE

To describe male patients (pts) with psychogenic nonepileptic seizures (PNESs) followed up in a Veteran's Administration (VA) seizure clinic and to compare them with those with epileptic seizures (ESs) by using clinical, and psychosocial variables.

METHODS

Adult male veterans seen between 1997 and 2000 with ESs were compared with those with PNESs with respect to clinical history (head trauma, antiepileptic drug exposure, depression, anxiety, substance abuse, seizure description), documented chronic pain, posttraumatic stress disorder (PTSD), compensation for diagnosis, neurologic examination, and test results including imaging and EEG data.

RESULTS

Men with PNESs were younger and reported more frequent events, and diagnoses of chronic pain, anxiety, and PTSD were significantly greater. Neuroimaging [computed tomography (CT) or magnetic resonance imaging (MRI) of the brain] and neurologic examination were significantly more likely to be normal or nonspecific in pts with PNESs, although history of ictal urinary incontinence or service-connected compensation for diagnosis did not distinguish the groups.

CONCLUSIONS

Male veterans with PNESs have characteristics similar to those reported in the literature, even though younger women have dominated previously studied populations. Compared with men with ESs, those with PNESs are more likely to have chronic pain, anxiety, and PTSD, as well as normal examinations and brain imaging.

An integrated neuropsychiatric approach to diagnosis and management of patients with epileptic seizures

In patients who present to neurology settings with history of epileptic seizures, psychiatric disorders may be the sole manifestation of apparent neurologic symptoms, or they may coexist. Current challenges for clinicians include distinguishing between two disorders and making the correct diagnoses, interpreting test results, and (co-) managing the disorder(s). Our goal is to provide the clinician with an integrated neuropsychiatric approach for the triage, assessment (history, screening tools, examination, diagnostic tests), and treatment (neurologic and/or psychiatric) of these challenging patients. In particular, use of schemata, tables, and algorithms will offer step-by-step approaches and guidelines for the clinician. Recommendations are made for the indications for psychiatric consultation, and co-management is recommended for patients with emergencies, those who fail routine psychiatric treatments, and those with complex presentations or multiple comorbid conditions.

Headache Attributed to Psychiatric Disorder: A Case Series

The association between psychiatric illness and headache is widely recognized. However, cases in which psychiatric disorders are the principal cause of headache are believed to be rare. "Headache attributed to psychiatric disorder" is a new category of secondary headache in the 2004 revision of the International Classification of Headache Disorders. The authors describe six patients in whom a psychiatric disorder is the most plausible cause of headache; most meet the new criteria or candidate criteria for headache attributed to a psychiatric disorder. The revised headache classification system appropriately recognizes headaches attributed to psychiatric disorder as a form of secondary headache.

Cluster analysis of normal personality traits in patients with psychogenic nonepileptic seizures

The literature on patients with psychogenic nonepileptic seizures (PNES) suggests that they are a heterogeneous population. This study addresses this heterogeneity by describing subtypes of PNES based on a cluster analysis of normal personality traits in patients with PNES. In addition, the identified PNES subtypes are further described on dimensions of psychopathology as measured by the Minnesota Multiphasic Personality Inventory, Second Edition (MMPI-2), and cognition. Three personality clusters emerged: (1) very high neuroticism, low extraversion, low openness, high agreeableness, low conscientiousness; (2) average on all domains; (3) very high neuroticism, average extraversion, low openness, low agreeableness, average conscientiousness. Patients in clusters 1 and 3 appear to exhibit more severe psychopathology and a broader range of symptoms than those in cluster 2. Based on NEO-PI-R and MMPI-2 findings, tentative descriptions of the clusters are offered. Cluster 1 comprises "depressed neurotics"; cluster 2, "somatic defenders"; and cluster 3, "activated neurotics." Clusters 1 and 3 also differ significantly on neurocognitive testing, with cluster 1 significantly lower than cluster 3 in memory functioning, while cluster 2 individuals show generally average cognition across domains. These results suggest the existence of personality subtypes in patients with PNES that should be considered in the design of interventions for them.

Posttraumatic stress disorder, dissociation, and sexual abuse history in epileptic and nonepileptic seizure patients

Rates of posttraumatic stress disorder (PTSD), dissociative symptoms, and childhood sexual abuse (CSA) are believed to be higher among patients with nonepileptic seizures (NES) than those with epileptic seizures (ES). However, women have higher rates of CSA and sexual assault than men. Comparisons of seizure type controlling for gender may produce different results. Data from an opportunity sample of 34 patients with ES and 17 with NES evaluated during or following phase 1 video-EEG monitoring demonstrated that patients with NES had statistically higher rates of PTSD and CSA and higher Dissociative Experiences Scale (DES) scores than patients with ES. No differences were found between women with NES and ES for histories of PTSD or CSA. Mean between-group DES score differences remained. Results indicated that PTSD, dissociation, and CSA may be common among women presenting to a tertiary epilepsy referral center for both ES and NES. Neither a positive history of CSA nor a history of PTSD was evidence against epilepsy.

Decreased bispectral index as an indicator of syncope before hypotension and bradycardia in two patients with needle phobia

We report two cases who exhibited a decrease in their bispectral index (BIS) score, associated with syncope during venipuncture in patients with suspected needle phobia. In case 1, the reduction in BIS score occurred during the development of hypotension and bradycardia and may well have been caused by cerebral hypoperfusion. In case 2, the patient lost consciousness with decreasing BIS score before hypotension and bradycardia; this patient's condition could not be completely explained by cerebral hypoperfusion as a result of a vasovagal reflex because the patient's blood pressure and heart rate remained normal during the syncopal episode.

Associated features of conversion disorder in Turkish adolescents

BACKGROUND

Conversion disorder in adolescents has not been studied extensively. A limited number of studies have focused on the features related to conversion disorder in adolescents. However, most of these studies used either retrospective data or did not have a control group that would allow comparison with the index cases.

METHODS

Fifty-two Turkish adolescent patients diagnosed with conversion disorder were compared with a control group of 52 adolescents diagnosed with psychiatric disorders other than conversion disorder. The data were collected from the adolescent subjects and their mothers by various questionnaires, inventories, and psychiatric interviews.

RESULTS

In the present study, pseudoseizures were the most common subtype of conversion disorder, followed by motor symptoms or deficits. Coming from a rural area, having a broken family, long-term separation from parents, problems related to communication and expression of emotions in the family, higher anxiety scores, conversion disorder in the proximal environment, and conversion disorder or other psychiatric disorders in the mother were significantly associated with conversion disorder in adolescents.

CONCLUSIONS

The findings of the present study are in accordance with existing findings, and amplify the importance of problems in family functioning in the etiology of conversion disorder.

Quality of life in psychogenic nonepileptic seizures

PURPOSE

Psychogenic nonepileptic seizures (PNESs) are events that alter or seem to alter the neurologic function and, in their appearance, resemble epileptic seizures (ESs). In patients with ESs the psychological and medical aspects of epilepsy greatly influence the health-related quality of life (HRQOL). The relation between these factors and PNESs is not well established. In this study, we compared HRQOL in patients with PNESs with that of patients with ESs.

METHODS

We evaluated 105 patients admitted to the Epilepsy Monitoring Unit of University Hospital between January 20, 2001, and January 20, 2002. Only patients with the definite diagnosis of ESs or PNESs were analyzed (n = 85). Patients completed an epilepsy-specific quality-of-life instrument (QOLIE-89), the Profile of Mood States (POMS), and Adverse Events Profile (AEP). We used t tests and regression analyses to contrast HRQOL in PNESs and ESs and to elucidate the main factors associated with HRQOL in patients with PNESs.

RESULTS

In our sample, 45 patients had PNESs, and 40 had ESs. The overall HRQOL and scores on 13 of 19 QOLIE-89 subscales were significantly lower (i.e., worse) in PNES than in ES patients. AEP and scores on five of six POMS subscales also were worse in PNES patients than in ES patients. PNES versus ES diagnosis, POMS depression/dejection, and AEP were significant predictors of HRQOL, jointly explaining 65% variation in HRQOL. The lower HRQOL in PNESs versus ESs was in part explained by depression and AEP.

CONCLUSIONS

Patients with PNESs have a lower HRQOL and worse mood problems than do patients with ESs. This disadvantage is primarily due to depression and medication side effects, although these factors influence QOL in much the same way in PNES and ES patients. These baseline HRQOL data on patients with PNESs can be used to evaluate the effects of treatment in this patient population.

Clinical Manifestations and Management of Conversion Disorders

Conversion disorder, the acute onset of sensory or motor loss unexplained by physical findings, has long been reported in the neurologic and psychiatric literature. It was once thought to be largely covariate with the "hysterical" (now referred to as "histrionic") personality, but recent work finds that conversion disorder more often presents in the absence of this personality disorder. Conversion disorder may also be part of a chronic pattern of physical expression of psychologic distress known as somatization disorder. Other psychiatric illnesses (particularly mood and anxiety disorders) are frequently comorbid, and conversion disorder and their treatment may affect the prognosis of conversion disorder symptoms. The neurologist suspecting a case of conversion disorder is advised to complete a thorough neurologic evaluation, and to have a low threshold for psychiatric consultation, which facilitates prompt comanagement that may increase the likelihood of a return to premorbid function.

Treatment of nonepileptic seizures

Studies on nonepileptic seizures (NES) provide dichotomous data sets: extensive observational findings, but a paucity of controlled treatment data. Psychosocial stressors, whose full impact may lie outside a patient's awareness, often underlie NES. These stressors, along with patient's learned patterns of coping, may bring forth or potentiate comorbid psychiatric disorders. Patients with NES often have dysfunction in emotion regulation and family dynamics, as well as unemployment/disability. High percentages of comorbid disorders such as major depressive disorder, post-traumatic stress disorder, and cluster B personality with impulsivity (all disorders associated with serotonin system function) also exist in the NES population. The preliminary observational evidence suggests that specific psychotherapies and pharmacotherapy directed at comorbid conditions may be the most effective treatment for NES.

Quality of life outcome is associated with cessation rather than reduction of psychogenic nonepileptic seizures

The outcome of psychogenic nonepileptic seizures (NES) is usually judged by recurrence of spells, but functional outcome or quality of life (QOL) is less well described. We tested the hypothesis that a decrease in NES recurrence yields corresponding improvement in QOL. Patients with NES were diagnosed with continuous video-EEG. We determined spell rate and QOL through a telephone interview at least six months after diagnosis. Thirty subjects consented to a follow-up interview (mean 17.4+/-1.5 months between diagnosis and interview). The rate of NES per week decreased significantly, and 10/30 (33%) had complete resolution. QOL, measured by the QOLIE-10 scale, did not improve proportionately with reduction in NES. However, subjects who reported a cessation of NES noted a significantly better total QOLIE-10 score (20.7+/-2.2) than those with continuing NES (27.4+/-1.6, P=0.02 by unpaired t test). Cessation rather than reduction of NES is associated with better QOL outcome.

A review of diagnostic techniques in the differential diagnosis of epileptic and nonepileptic seizures

The diagnosis of psychogenic nonepileptic seizures (PNES) is complex. Long-term electroencephalogram monitoring with video recording (video EEG) is the most common method of differential diagnosis of epilepsy and PNES. However, video EEG is complex, costly, and unavailable in some areas. Thus, alternative diagnostic techniques have been studied in the search for a diagnostic method that is as accurate as video EEG, but more cost effective, convenient, and readily available. This paper reviews the literature regarding possible diagnostic alternatives and organizes findings into 7 areas of study: demographic and medical history variables, seizure semiology, provocative testing, prolactin levels, single photon emission computed tomography, psychological testing, and neuropsychological testing. For each area, the literature is summarized, and conclusions about the accuracy of the technique as a diagnostic tool are drawn. Overall, it appears unlikely that any of the reviewed alternative techniques will replace video EEG monitoring; rather they may be more successful as complementary diagnostic tools. An important focus for further investigations involves combinations of diagnostic techniques for the differential diagnosis of epilepsy and PNES.

Psychological Treatment of Nonepileptic Events

Nonepileptic events (NEEs) occur with and without true seizure disorders and vary greatly in clinical presentation. They are often associated with significant psychopathology. This paper proposes six categories of NEE patients based on psychosocial history, NEE etiology, and mechanisms of and response to psychotherapy. A series of 26 adult NEE patients were grouped according to six symptom patterns: (a) acute anxiety/panic, (b) impaired affect regulation and interpersonal skills, (c) somatization/conversion, (d) depression, (e) posttraumatic stress disorder, and (f) reinforced behavior pattern. Classification was made on the basis of the specific psychotherapeutic interventions found most effective with each patient group.

Detecting the Malingering of Seizures

We present the case report of a patient who manifested seizures due to malingering, and discuss the differential diagnosis. The characteristics typical of nonepileptic seizures not due to malingering and of seizures due to malingering are described. Methods of distinguishing nonepileptic seizures from epileptic seizures are outlined, and the differences between seizures due to malingering and other nonepileptic seizures are discussed.

Psychiatric implications of surgical treatment of epilepsy

Clinicians must consider the psychiatric issues relevant to patients undergoing neurosurgical procedures for epilepsy. Obtaining the patient's psychiatric history can facilitate stabilizing the patient's condition before operative intervention. Preoperatively, depressive and anxiety disorders are the most common psychiatric conditions diagnosed in candidates for surgical treatment of epilepsy. Although psychotic disorders occur infrequently, they demand attention because symptoms may interfere with patient compliance with follow-up care. Patients with chronic psychotic symptoms who have ongoing seizures postoperatively and bilateral seizure foci are at higher risk for a poor outcome and postoperative psychosis. When psychiatric disorders are present, surgical management is not contraindicated, but preoperative psychiatric intervention may be warranted. Most patients have a favorable outcome with the elimination of seizures, which simplifies the subsequent treatment of a psychiatric disorder.