Treatment of posttraumatic epilepsy with new generation antiepileptic drugs (AEDs) - our experience

Aim To investigate influence of therapy with new generation antiepileptic drugs (AEDs) in fastening of posttraumatic epilepsy (PTE) remission comparing to therapy with standard AEDs, as well as the time to remission in the presence of psychiatric comorbidities. Methods The study was conducted during the 1988-2008 period and included 113 patients (47 females and 67 males) with PTE and 113 patients (93 females and 20 males) suffering from complex partial seizures (CPS) of temporal lobe origin. In both patient groups, epileptic seizure phenotype, brain magnetic resonance imaging (1.5 T and 3.0 T) and electroencephalogram were analyzed within 24 hours of epileptic seizure and after 5 years of treatment. Psychological testing was administered prior to therapy initiation. Results The patients treated with standard AEDs achieved remission in 82 (73%) cases as compared with 87 (77%) patients administered with a new generation AEDs; in the latter group, remission was achieved faster (1.85 vs. 1.6 months). In both patient groups, psychiatric comorbidity prolonged time to remission by 3.4 months. Conclusion Therapy with new generation AEDs enables achieving faster and complete remission in PTE patients.

Lamotrigine treatment of a patient affected by epilepsy and anxiety disorder

Epilepsy often occurs in comorbidity with mental diseases and disorders. Early detection and/or treatment of such disorders in patients affected by epilepsy, as well as their socialisation are crucially important since epileptic patients tend to suffer more due to lack of social support than to frequent epileptic seizures. Prevalence of psychiatric disorders is higher in patients with epilepsy than in general population, the most frequent being: anxiety, depression, panic attacks, behavioural disorders as well as psychotic states with paranoid elements. The efficacy of AE treatment of patients affected by epilepsy and mood disorders has also directed clinicians to investigate possible AE benefits in treating other mental disorders such as anxiety states, depression and bipolar disorder. The examined case displays complex partial epilepsy and comorbid mental disorder. The use of lamotrigine, a fourth-generation antiepileptic, which is also a mood stabilizer, has assured a favourable remission of symptoms related to both epilepsy and mood disorders. Side-effects caused by lamotrigine were only temporary and dose reduction was sufficient to eliminate their symptoms.

Theories of impaired consciousness in epilepsy

Although the precise mechanisms for control of consciousness are not fully understood, emerging data show that conscious information processing depends on the activation of certain networks in the brain and that the impairment of consciousness is related to abnormal activity in these systems. Epilepsy can lead to transient impairment of consciousness, providing a window into the mechanisms necessary for normal consciousness. Thus, despite differences in behavioral manifestations, cause, and electrophysiology, generalized tonic-clonic, absence, and partial seizures engage similar anatomical structures and pathways. We review prior concepts of impaired consciousness in epilepsy, focusing especially on temporal lobe complex partial seizures, which are a common and debilitating form of epileptic unconsciousness. We discuss a "network inhibition hypothesis" in which focal temporal lobe seizure activity disrupts normal cortical-subcortical interactions, leading to depressed neocortical function and impaired consciousness. This review of the major prior theories of impaired consciousness in epilepsy allows us to put more recent data into context and to reach a better understanding of the mechanisms important for normal consciousness.

Patient awareness of seizures as documented in the epilepsy monitoring unit

Treatment for epilepsy depends largely on seizure frequency reported by patients through their seizure diaries. However, patients may be unaware of some of their seizures, which may lead to incomplete diary data, impacting on appropriate treatment plans. The purpose of this study was to quantify awareness of seizures in patients admitted to an epilepsy monitoring unit through post event assessments by registered nurses. Results indicated that only 44.5% of complex partial and secondarily generalized tonic-clonic seizures were recognized by patients with epilepsy. Incomplete data in seizure diaries are likely a widespread problem, which may have an important impact on treatment and, thereby, on the safety and quality of life of individuals with epilepsy.

Subacute postictal aggression in patients with epilepsy

Three men with epilepsy (age range, 38-62) who exhibited brief episodes of violent behavior during the postictal period are described. Disease duration ranged from 27 to 44 years. Patients had both complex partial seizures and secondarily generalized tonic-clonic seizures, which were refractory to antiepileptic drugs. Postictal aggression occurred shortly after a seizure and lasted 5-30 minutes. The patients displayed physically and verbally aggressive behavior toward others, but regained consciousness promptly and showed regret afterward. Interictal EEGs revealed temporal spikes, SPECT showed hypoperfusion in the temporal and frontal areas in two patients, and neuropsychological examination revealed poor frontal lobe function in two patients. Characteristics of our cases are consistent with subacute postictal aggression (SPA) reported previously. Epilepsy of prolonged duration and brain dysfunction involving a broad area including the temporal and frontal lobes may be associated with the occurrence of subacute postictal aggression.

Psychosocial adjustment following relief of chronic narcolepsy

BACKGROUND AND PURPOSE

No previous research has examined the psychosocial adjustment of chronic narcolepsy patients following efficacious pharmacotherapy. In contrast, considerable research has examined the process of psychosocial adjustment following surgical relief of chronic epilepsy. This process can manifest as a clinical syndrome, the 'burden of normality', comprising psychological, behavioural, affective and sociological features. The aim of the present study was to characterise the process of psychosocial adjustment of patients with successfully treated narcolepsy and to explore the applicability of the burden of normality.

PATIENTS AND METHODS

Thirty-three narcolepsy patients and 31 epilepsy surgery patients were recruited through routine outpatient follow-up at the Austin Hospital in Melbourne. All patients underwent in-depth, qualitative psychosocial assessment using a well-validated semi-structured interview, the Austin CEP Interview. They were also administered quantitative measures of anxiety (State Trait Anxiety Inventory) and depression (Beck Depression Inventory-II).

RESULTS

Narcolepsy patients spontaneously reported similar themes of post-treatment adjustment to successfully treated epilepsy patients, including symptoms of the burden of normality. Chi-squared analyses revealed that the two groups differed only on disease-specific factors, reflecting the later diagnosis and treatment of narcolepsy (P<0.05).

CONCLUSION

The results support a general model of adjustment following successful treatment of chronic neurological illness, as the patient discards perceptions of illness and behaviours associated with being 'sick' and learns to become 'well'. Recognition of the burden of normality has important clinical implications for maximising the post-treatment care and outcome of narcolepsy patients.

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.

[Induction of pseudoseizures by placing inactive electrodes in the malar regions]

INTRODUCTION

Pseudoseizures are paroxysmal disorders of a psychogenic origin with manifestations that are similar to epileptic seizures. They constitute a pathology that is found relatively often in the clinical practice of neurology. In many cases the diagnostic suspicion of their existence is difficult to confirm. The complementary examination that proves to be most useful in diagnosing them is video electroencephalogram (video-EEG).

CASE REPORTS

We report the cases of seven patients who were referred to our service with a clinical suspicion of pseudoseizures. Placing electrodes with an inactive surface-coating over the two malar regions during a video-EEG study enabled us to trigger in all patients (by means of suggestion) the appearance of a clinical picture that was similar to those that initially gave rise to the request for an examination. Suggestion was also employed to limit the time they lasted by getting the patient to resolve the episode. In all the cases the trace of the simultaneous electroencephalogram showed no pathological findings.

CONCLUSIONS

Placing inactive electrodes on malar regions is a method for inducing pseudoseizures that is harmless, easily applicable, readily available and economical, and which has not been reported in the literature. Video-EEG monitoring time is reduced using this approach. It provides evidence that a specific seizure phenomenon can be induced and resolved by suggestion techniques, which is a fact that is very useful in the diagnosis of pseudoseizures.

Patient Awareness of Complex Partial Seizures

PURPOSE

To assess self-awareness of complex partial seizures (CPSs) in unselected epilepsy patients through a thorough interview.

METHODS

The study comprised 134 patients at our epilepsy clinic, whose CPSs had been documented by the patient's family members. We investigated the proportion and characteristics of patients unaware of their CPSs compared to those who were, and we monitored the evolution of unawareness of CPSs during the follow-up.

RESULTS

Thirty-one (23%) patients were assigned to the unawareness group (complete, 23; incomplete, 8) and 103 (67%) patients to the awareness group. Patients in the unawareness group were older and had a later age of onset than patients in the awareness group. Interictal epileptiform discharges (IEDs) localized primarily to the temporal region and were more frequently detected in the unawareness group (94%) than the awareness group (55%). Bilateral independent IEDs were found more frequently in the unawareness group than in the awareness group (48% vs. 13%). The bilateral presence of lesions was also more frequent in the unawareness group than the awareness group (16.1% vs. 4.9%). Six (26%) of 23 patients with complete unawareness of their CPSs had experienced awareness of CPSs during the follow-up. Two of these patients even experienced the emergence of de novo aura.

CONCLUSIONS

Our results indicate that a significant number of epilepsy patients are not aware of their CPSs. Unawareness of CPSs may be related to bitemporal dysfunction and a rapid and complete loss of consciousness caused by rapid spread of ictal discharges to the contralateral hemisphere in association with bilateral independent IEDs and bilateral presence of lesions.

Postictal behaviour in temporal lobe epilepsy

Postictal phenomena such as nose-wiping, coughing and hypersalivation are believed to reflect a purposeful reaction to hypersecretion after regaining consciousness following a complex partial seizure, and are very common in patients with temporal lobe epilepsy, particularly in mesial temporal lobe epilepsy. Nose-wiping is usually performed with the hand ipsilateral to the side of seizure onset. Our patient illustrates an unusual, exaggerated postictal behaviour consisting of long-lasting nose-wiping, coughing and guttural sounds following a complex partial seizure due to right mesial temporal lobe epilepsy. [Published with video sequences].

Risk factors for depression in patients with epilepsy

PURPOSE

Symptoms of depression are present in 40 to 60 percent of patients with epilepsy. Prior research indicated significant correlation between the incidence and frequency of focal seizures and clinical depression, especially in patients with temporal lobe epilepsy. Anticonvulsive drugs and psychosocial factors contribute to the occurrence of depression as well. The aim of the study was to determine the major depression risk factors in patients with epilepsy.

METHODS

The research was conducted on 203 patients with epilepsy (117 females and 86 males), aged 18 to 50 years, with total time of illness ranging from 60 to 580 months. All subjects underwent the same research protocol, which was applied interictally. Interictal depression was diagnosed according to ICD-10 diagnostic criteria for affective and delusional disorders. The diagnosis was supported by Beck Depression Inventory (BDI), Hamilton Depression Rating Scale (HAM-D) and Montgomery-Asberg Depression Rating Scale (MADRS). Statistical analysis included chi2 test, Fisher's exact test and stepwise logical regression model analysis.

RESULTS

In our study 100 patients with epilepsy out of 203 suffered from concurrent depression (49.2%); 76 of them had severe depression (37.4%) and 24 patients had mild depression (11.8%). Complex partial seizures and absence of secondary generalized tonic-clonic seizures were found to be the risk factors for depression. Treatment with clonazepam, frequent hospitalizations (drug-resistancy) and lack of occupational activity were revealed to be additional significant contributing factors.

CONCLUSIONS

Depression in patients with epilepsy is a serious medical and social problem since it afflicts almost one half of all patients treated in epilepsy referral centers. It seems to be correlated with certain types of epileptic seizures, with high frequency of seizures, sub-optimal pharmacologic treatment and lack of occupational and social activity.

Cortical sites critical for speech discrimination in normal and impaired listeners

We used statistical modeling to investigate variability in the cortical auditory representations of 24 normal-hearing epilepsy patients undergoing electrocortical stimulation mapping (ESM). Patients were identified as normal or impaired listeners based on recognition accuracy for acoustically filtered words used to simulate everyday listening conditions. The experimental ESM task was a binary (same-different) auditory syllable discrimination paradigm that both listener groups performed accurately at baseline. Template mixture modeling of speech discrimination deficits during ESM showed larger and more variable cortical distributions for impaired listeners than normal listeners, despite comparable behavioral performances. These results demonstrate that individual differences in speech recognition abilities are reflected in the underlying cortical representations.

Older adults with epilepsy demonstrate cognitive impairments compared with patients with amnestic mild cognitive impairment

Little is known about the cognitive effects of chronic epilepsy in older adults. To better characterize cognitive impairment in seniors with epilepsy, we compared cognitive performance of 26 seniors with epilepsy with that of 26 well-matched patients with mild cognitive impairment (MCI) and 26 well-matched healthy older adults. Participants completed neuropsychological testing with the Dementia Rating Scale (DRS), Logical Memory, and CFL Word Fluency. There were no significant demographic group differences, although seniors with epilepsy had higher self-reported depression. Seniors with epilepsy performed below controls on virtually all neuropsychological tests, and performed below patients with MCI on DRS Total score, Initiation/Perseveration, and CFL Fluency. Seniors with epilepsy on antiepileptic drug (AED) polytherapy had the most severe cognitive deficits, whereas seniors with epilepsy on AED monotherapy were comparable to cholinesterase inhibitor-naïve patients with MCI. This study emphasizes the clinical importance of cognitive impairment in seniors with epilepsy and highlights the need for future studies addressing causes and treatment of cognitive impairment.

A comparative study of mismatch negativity (MMN) in epilepsy and non-epileptic seizures

This study investigated mismatch negativity (MMN) differences between subjects with non-epileptic seizures (NES), subjects with epilepsy, and healthy controls. Event-related potentials (ERPs) were obtained from 14 patients with NES, 15 patients with epilepsy and 16 healthy control subjects. A conventional MMN procedure was used with a random sequence of 12% deviant tones (922 Hz) and 88% standard tones (1000 Hz). Subjects were instructed to ignore the tones delivered through headphones whilst reading a book. Significant differences in distribution of the mismatch negativity (MMN) in patients with NES compared to controls were obtained (F3, p <or= 0.019; Cz, p <or= 0.044) and longer MMN duration in patients with epilepsy compared with patients with NES (p <or= 0.039) was observed. The change that has been analyzed is one of relative (or scaled) amplitude rather than absolute amplitude. These differences observed at Cz/F3 suggest an increase in emphasis of the MMN in the frontocentral region in patients with NES compared to healthy controls, suggesting that the MMN is generated in a different way in NES compared with controls. This could indicate that one of the normal MMN generator areas does not function normally in NES. Increased absolute amplitude of the MMN has previously been observed in anxiety disorders particularly in post-traumatic stress disorder (PTSD). We discuss similarities between NES and PTSD, suggesting that the increased relative amplitude obtained in this study may be related to mechanisms of generation of NES. The prolonged duration of the MMN in epilepsy could be related to difficulties in processes associated with novelty discrimination (closure of MMN generating mechanism). This information processing dysfunction could be associated with the concentration and memory difficulties that are observed in some patients with epilepsy. This study provides electrophysiological evidence of abnormal processing of auditory stimuli in both clinical conditions when compared to healthy controls, and interictal differences between a group of patients with epilepsy and a group of patients with non-epileptic seizures, as measured by the MMN.

Depression and Anxiety Disorders in Pediatric Epilepsy

PURPOSE

This study examined affective disorders, anxiety disorders, and suicidality in children with epilepsy and their association with seizure-related, cognitive, linguistic, family history, social competence, and demographic variables.

METHODS

A structured psychiatric interview, mood self-report scales, as well as cognitive and language testing were administered to 100 children with complex partial seizures (CPSs), 71 children with childhood absence epilepsy (CAE), and 93 normal children, aged 5 to 16 years. Parents provided behavioral information on each child through a structured psychiatric interview and behavior checklist.

RESULTS

Significantly more patients had affective and anxiety disorder diagnoses (33%) as well as suicidal ideation (20%) than did the normal group, but none had made a suicide attempt. Anxiety disorder was the most frequent diagnosis among the patients with a diagnosis of affective or anxiety disorders, and combined affective/anxiety and disruptive disorder diagnoses, in those with suicidal ideation. Only 33% received some form of mental health service. Age, verbal IQ, school problems, and seizure type were related to the presence of a diagnosis of affective or anxiety disorder, and duration of illness, to suicidal ideation.

CONCLUSIONS

These findings together with the high rate of unmet mental health underscore the importance of early detection and treatment of anxiety disorders and suicidal ideation children with CPSs and CAE.

Social competence in pediatric epilepsy: insights into underlying mechanisms

This study compared parent-based Child Behavior Checklist (CBCL) social competence scores of 90 children with complex partial seizures (CPS) and 62 with absence epilepsy (CAE) of average intelligence with scores of 91 healthy children. It also examined the role of seizure-related, cognitive, behavioral, linguistic, social communication, and demographic variables on these measures. When differences in cognitive, linguistic, and demographic variables were controlled for, the CPS and CAE groups had significantly lower scores in the school, but not in the social interaction and activities domains compared with the healthy control group. Among the patients, lower Full Scale IQ externalizing behaviors, disruptive disorders, minority status, and impaired social communication, but not seizure variables, predicted lower social competence scores. These findings demonstrate the importance of controlling for cognitive, behavioral, and demographic variables in social competence studies of children with CPS and CAE and the need to assess cognition and behavior when parents report school and social problems in these children.

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

PURPOSE

To evaluate if degree of anxiety proneness is affected by seizure outcome after epilepsy surgery.

METHODS

Five scales related to anxiety, which are part of the Karolinska Scales of Personality (KSP), were administered pre-operatively and 2-8 years post-operatively to 31 female and 26 male patients. High scores indicate a high degree of anxiety. Seizure outcome was either Engel I or Engel II-IV.

RESULTS

Mean age of the patients was 39 years (S.D. 10). Forty-seven patients had temporal surgery and 10 patients had extra-temporal surgery. The outcome in 34 patients was classified as Engel I and in 23 patients as Engel II-IV. There were statistically significant decreases (paired t test) in t scores for the Somatic Anxiety scale (expected mean 50, from 55.4 to 50.2, P = 0.001) and the Psychic Anxiety scale (expected mean 50, from 56.2 to 51.6, P = 0.006) in patients in Engel I. No other significant differences were observed. After taking baseline imbalances into account (ANCOVA), there were no statistically significant differences in the change in degree of anxiety proneness between patients in the two outcome groups.

CONCLUSION

Patients undergoing successful epilepsy surgery experienced small decreases in somatic anxiety and psychic anxiety. Since there were important pre-operative imbalances between the two outcome groups, these differences could not be attributed to the effect of seizure freedom after epilepsy surgery.

Intelligence functions disorders in patients with complex partial epilepsy

OBJECTIVES: To compare the performance of patients with complex partial epilepsy with the normal controls in the subtests of an instrument used to assess intelligence function. METHOD: Fifty epileptic patients, whose ages ranged from 19 to 49 years and 20 normal controls without any neuropsychiatric disorders. The Wechsler-Bellevue adult intelligence test was applied in groups, epileptic patients and control subjects. This test is composed of several subtests that assess specific cognitive functions. A statistical analysis was performed using non-parametric tests. RESULTS: All the Wechsler-Bellevue subtests revealed that the intelligence functions of the patients were significantly inferior to that of the controls (p<0.05). This performance was supported by the patient's complaints in relation to their cognitive performance. CONCLUSION: Patients with complex partial epilepsy presented poorer results in the intelligence test when compared with individuals without neuropsychiatric disorders.

Psychopathology and Pediatric Complex Partial Seizures: Seizure-related, Cognitive, and Linguistic Variables

PURPOSE

This study examined the role of cognition, language, seizure-related, and demographic variables in the psychopathology of children with complex partial seizure disorder (CPS) of average intelligence.

METHODS

One-hundred one CPS and 102 normal children, aged 5.1 to 16.9 years, had a structured psychiatric interview and cognitive and language testing. Parents provided demographic, perinatal, and seizure-related information, as well as behavioral information through the Child Behavior Checklist (CBCL) and a structured psychiatric interview about the child.

RESULTS

Significantly more CPS patients had psychopathology, cognitive deficits, and linguistic deficits than did those in the normal group. Among the patients, Verbal IQ predicted the presence of a psychiatric diagnosis, as well as CBCL scores in the borderline/clinical range. Seizure, linguistic, and demographic variables were unrelated to psychopathology. The cognitive and linguistic deficits of the CPS group, however, were predicted by seizure factors (e.g., prolonged seizures/febrile convulsions; seizure frequency/number of antiepileptic drugs) and demographic factors (e.g., minority status).

CONCLUSIONS

Because subtle verbal cognitive deficits predict behavioral disturbances in pediatric CPSs, the study's findings highlight the importance of assessing behavior, cognition, and language in these children. They also underscore the negative impact of prolonged seizures, febrile convulsions, seizure frequency, and antiepileptic drug polytherapy on cognition and language in pediatric CPSs.

Prescience as an Aura of Temporal Lobe Epilepsy

PURPOSE

A patient with a distinct aura of prescience as a manifestation of temporal lobe epilepsy was encountered. The experience prompted a review of this ictal phenomenon among patients attending a tertiary care epilepsy outpatient clinic.

METHODS

A computer epilepsy database was searched for patients with simple partial sensory seizures and complex partial seizures with auras. Identified patients had charts reviewed for details of the auras; patients were contacted and asked to provide written descriptions of their experiences. Literature searches (PubMed) were done by using the terms "precognition" or "prescience" and "seizures" or "epilepsy." Standard comprehensive epilepsy textbooks were reviewed.

RESULTS

The charts of 218 patients were reviewed from 927 in the database; three had prescience as an ictal feature. The patients' descriptions were very similar in all cases (a profound sense of "knowing" what was going to happen in their environment in the immediate future). The experience was distinct from déjà vu and other psychic experiences. All patients probably have temporal lobe epilepsy. Only one other description of prescience as an ictal feature was found in the literature.

CONCLUSIONS

Prescience can occur as an ictal feature of temporal lobe epilepsy and represents a previously underreported psychic phenomenon. The potential lateralizing value of this symptom is yet to be determined.

Dream experience during REM and NREM sleep of patients with complex partial seizures

This study examined the effectiveness of the cognitive processes underlying dreaming in patients with complex partial seizures (CPS), by assessing the frequency of recall and the structural organization of dreams reported after awakenings provoked alternately during REM and stage 2 NREM sleep on 12 cognitively unimpaired CPS-patients (six with epileptic focus in the right hemisphere and six in the left one). Each patient was recorded for three consecutive nights, respectively, for adaptation to the sleep laboratory context, for polysomnography and for dream collection. The frequency of dream recall was lower after stage 2 NREM sleep than REM sleep, regardless of the side of epileptic focus, while the length and structural organization of dreams did not significantly differ in REM and NREM sleep. However, the length of story-like dreams was influenced by global cognitive functioning during REM sleep. These findings indicate that in CPSs-patients the elaboration of dream experience is maintained in both REM and NREM sleep, while the access to information for conversion into dream contents and the consolidation of dream contents is much less effective during NREM rather than during REM sleep. Further studies may distinguish between these two possibilities and enlighten us as to whether the impaired memory functioning during NREM sleep is a side effect of anticonvulsant treatment.

[Psychosis in a case of temporal lobe epilepsy associated with a dysembryoplastic neuroepithelial tumour]

INTRODUCTION

Psychosis is an acknowledged, although infrequent, complication that occurs in 0.5 9% of all cases of epilepsy. In this work, we present a case of complex partial epilepsy due to a dysembryoplastic neuroectodermal tumour in the right hippocampus, which began as acute psychosis and was cured following its surgical removal. Both its aetiology and its pathogenesis are discussed.

CASE REPORT

We describe the case of a 17 year old male with a family history of schizophrenia. While studying his last years of secondary education, and apparently well adapted, he was taken into custody and hospitalised urgently because of personality disorders. The patient suffered from somatic and auditory hallucinations, simple visual pseudohallucinations, formal alterations to his thinking, cosmovisions, delusions of influence, persecution, grandeur and of a mystic nature, with no other neurological focus. At the same time, the patient also had complex partial seizures. Magnetic resonance imaging revealed a cystic tumour in the right temporal lobe. Pathology laboratory findings showed a dysembryoplastic neuroepithelial tumour. For a period of two years following surgical removal, the schizophrenic symptoms and the complex partial seizures disappeared and the patient no longer required antipsychotic medication.

CONCLUSIONS

Epileptic psychosis may be related to pathological conditions of the hippocampus. In this study we present what we believe to be the first case of a dysembryoplastic neuroepithelial tumour giving rise to such psychosis. Surgical removal of the tumour cured both entities.

Recurrent seizures: an unusual manifestation of vitamin B12 deficiency

The present report highlights an unusual presentation of vitamin B12 deficiency--recurrent seizures in a 26-year-old man. His symptoms responded to parenteral vitamin B12 therapy. The relevant literature is reviewed.

Out-of-body experience and autoscopy of neurological origin

During an out-of-body experience (OBE), the experient seems to be awake and to see his body and the world from a location outside the physical body. A closely related experience is autoscopy (AS), which is characterized by the experience of seeing one's body in extrapersonal space. Yet, despite great public interest and many case studies, systematic neurological studies of OBE and AS are extremely rare and, to date, no testable neuroscientific theory exists. The present study describes phenomenological, neuropsychological and neuroimaging correlates of OBE and AS in six neurological patients. We provide neurological evidence that both experiences share important central mechanisms. We show that OBE and AS are frequently associated with pathological sensations of position, movement and perceived completeness of one's own body. These include vestibular sensations (such as floating, flying, elevation and rotation), visual body-part illusions (such as the illusory shortening, transformation or movement of an extremity) and the experience of seeing one's body only partially during an OBE or AS. We also find that the patient's body position prior to the experience influences OBE and AS. Finally, in five patients, brain damage or brain dysfunction is localized to the temporo-parietal junction (TPJ). These results suggest that the complex experiences of OBE and AS represent paroxysmal disorders of body perception and cognition (or body schema). The processes of body perception and cognition, and the unconscious creation of central representation(s) of one's own body based on proprioceptive, tactile, visual and vestibular information-as well as their integration with sensory information of extrapersonal space-is a prerequisite for rapid and effective action with our surroundings. Based on our findings, we speculate that ambiguous input from these different sensory systems is an important mechanism of OBE and AS, and thus the intriguing experience of seeing one's body in a position that does not coincide with its felt position. We suggest that OBE and AS are related to a failure to integrate proprioceptive, tactile and visual information with respect to one's own body (disintegration in personal space) and by a vestibular dysfunction leading to an additional disintegration between personal (vestibular) space and extrapersonal (visual) space. We argue that both disintegrations (personal; personal-extrapersonal) are necessary for the occurrence of OBE and AS, and that they are due to a paroxysmal cerebral dysfunction of the TPJ in a state of partially and briefly impaired consciousness.

Improvement of aggressive and antisocial behavior after resection of temporal lobe tumors

Seizures associated with temporal lobe tumors may rarely manifest as episodic aggressive behavior. We describe 2 cases involving pediatric patients who presented with histories of unusually aggressive and antisocial behavior. Magnetic resonance imaging identified right mesial temporal lobe masses in both patients. After craniotomy for tumor removal, both patients were seizure-free and had marked reductions in their aggressive behavior. Tumors in the temporal lobe may be associated with behavioral problems, including aggression and rage attacks, which can be alleviated with surgical intervention. It is important to distinguish this subgroup of pediatric patients from those with alternative diagnoses such as attention-deficit/hyperactivity disorder or oppositional defiant disorder.

Quality of life after vagus nerve stimulation for intractable epilepsy: is seizure control the only contributing factor?

We assessed the impact of vagus nerve stimulation on a cohort of patients with intractable epilepsy. A 1-year prospective trial of vagus nerve stimulation for intractable epilepsy was done in 26 patients. Seizure frequency, anti-epileptic drugs, and quality of life were assessed using QOLIE-89, ELDQOL, and a Likert scale of impact of treatment. Seizures were reduced by more than 50% in 19% of the patients, by less than 50% in 46%, and were unchanged in 35% of them. Antiepileptic drugs were reduced in 43% of the patients. There was a significant improvement in the mean overall QOLIE-89 score and other measures of quality of life, but these did not correlate with changes in seizure frequency. Subjective improvement occurred in 84% of the patients. The quality of life improves in some patients following vagus nerve stimulation for intractable epilepsy. The favorable effects of this treatment may be attributable to additional factors besides seizure control which in this study was modest.

Topiramate and psychiatric adverse events in patients with epilepsy

PURPOSE

The aim of this study was to determine the prevalence of psychiatric adverse events (PAEs) in patients with epilepsy treated with topiramate (TPM). Classification, relation to TPM dosing, and outcome were evaluated to identify a patient profile at risk of developing PAEs.

METHODS

We evaluated the data of the first consecutive and prospectively collected patients in therapy with TPM.

RESULTS

Follow-up information was available for 431 patients. PAEs occurred in 103 (23.9%) patients; M/F ratio, 55:48; mean age (+/-SD), 36.5 +/- 11.2. In 46 (10.7%) patients, an affective disorder developed; in 16 (3.7%), a psychotic disorder; in 24 (5.6%), aggressive behavior with or without irritability; in 17 (3.9%), other behavior abnormalities such as agitated behavior, anger/hostility behavior, or anxiety. High starting dose and rapid titration schedule were relevant for the development of PAEs. Family psychiatric history and family history of epilepsy, personal history of febrile convulsions, psychiatric history, and presence of tonic-atonic seizures were found to be significant risk factors. Low seizure frequency before starting TPM and TPM/lamotrigine coadministration had a protective effect for PAEs.

CONCLUSIONS

We found that PAEs associated with TPM were related to the titration schedule of the drug and that a unique patient profile is suggested by the clinical history.

Behavioral disorders in pediatric epilepsy: unmet psychiatric need

PURPOSE

This study examined the relation between psychiatric diagnosis and mental health services in children with epilepsy and the associated demographic, cognitive, linguistic, behavioral, and seizure-related variables.

METHODS

The Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS), the Child Behavior Checklist, the Test of Language Development, and the Wechsler Intelligence Scale for Children-Revised (WISC-R) were administered to 114 children, aged 5 to 16 years, with either complex partial seizures (CPS) or primary generalized with absence (PGE, petit mal). A Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) diagnosis and information regarding mental health services were derived from the K-SADS.

RESULTS

Although approximately 60% of the subjects had a DSM-IV psychiatric diagnosis, >60% received no mental health treatment. Absence of mental health care was associated with younger age, less parental education, limited number of antiepileptic drugs (AEDs; i.e., one or none), and higher verbal IQ. In addition, children with PGE and a single psychiatric diagnosis were less likely to have a history of mental health treatment.

CONCLUSIONS

This is the first study to demonstrate unmet mental health need in a large sample of children with CPS and PGE. The study's findings suggest that parents and clinicians should be aware of the mental health needs of children with epilepsy, particularly if they have one or more of the identified risk factors.

Spirituality and complex partial epileptic-like signs

Using a sample of 262 undergraduate volunteers, correlational and regressional analyses were completed to examine the relation of self-reported complex partial epileptic-like signs to a five-dimensional model of spirituality assessed by the Expressions of Spirituality Inventory. Analyses show that spirituality is significantly predictive of Complex Partial Epileptic-like Signs. Scores from subscales Paranormal Beliefs, Experiential/Phenomenological Dimension, and Existential Well-being uniquely accounted for significant portions of Complex Partial Epileptic-like Signs variance. ESI Cognitive Orientation Toward Spirituality significantly correlated with Complex Partial Epileptic-like Signs but it was not a significant predictor in regression analyses. ESI Religiousness was unrelated to Complex Partial Epileptic-like Signs in all analyses. This pattern of relations remained largely the same when participants' age, sex, and reported religious involvement were controlled. The paper includes a discussion of the meaning of the findings and suggestions for research.

Psychoses and epilepsy: are interictal and postictal psychoses distinct clinical entities?

PURPOSE

To evaluate further the relevance of designating psychotic episodes as either postictal or interictal, we compared several biologic variables between epilepsy patients with and without psychosis.

METHODS

The study subjects comprised 282 patients with psychosis (36 with postictal psychosis, 224 with interictal psychosis, and 22 with both postictal and interictal psychoses, i.e., bimodal psychosis), and 658 epilepsy patients without psychosis. The clinical characteristics of these patients were reviewed retrospectively by experienced neuropsychiatrists. Factors predicting the development of each type of psychosis were determined by serial multivariate logistic regression analyses.

RESULTS

Factors that were comparable between postictal and interictal psychoses were intellectual function, family history of psychosis, epilepsy type, and the presence of complex partial seizures. In contrast, age at the onset of epilepsy and at the onset of psychosis and the presence of generalized tonic-clonic seizures differed for the three types of psychosis. Patients with bimodal psychosis showed characteristics associated with both postictal and interictal psychoses.

CONCLUSIONS

This study documented conditions, including both general factors and epilepsy-related factors, common to epilepsy patients with psychosis, regardless of chronologic distinctions. Certain epileptic processes appear to have equal influence on postictal and interictal psychoses. However, some differences between postictal and interictal psychoses suggest that these chronologic descriptors are valid. Our findings confirmed that psychosis associated with epilepsy should not be defined as a single, simple condition but rather as a complex condition with several possible subcategories.

Surgery for complex partial seizures

Dr. Girvin discusses the technique of surgery for complex partial seizures, some of the questions and controversies related to this technique and the probability of a successful outcome.

Dream recall frequency in epilepsy patients with partial and generalized seizures: a dream diary study

PURPOSE

The frequency of dream recall (DR) in patients with brain diseases has proved to be indicative of the relation between sleep disturbances and the functioning of cognitive processes during sleep. In this study we attempted to ascertain whether DR frequency in patients with complex partial seizures (CPSs) is higher than that in those with generalized seizures.

METHODS

DR frequency was assessed by means of a 60-day dream diary in patients with CPSs, whose epileptic focus was in the right (n = 12) or left temporal lobe (n = 28), and with idiopathic generalized seizures (n = 21). The patients enrolled in the study were not impaired in global cognitive and memory functioning.

RESULTS

The ability to recall dreams was established in nearly all patients with either CPSs or generalized seizures. DR frequency resulted significantly higher (about twice) in patients with CPSs, regardless of (a) the side of the epileptic focus, (b) the presence of a cerebral lesion detectable on a computed tomography (CT) scan, or (c) the occurrence of seizures in the previous day.

CONCLUSIONS

These findings indicate that overall, DR occurs in medicated epilepsy patients with CPSs more frequently than reported in previous studies. The high DR frequency observed in these patients, regardless of the side of the epileptic focus, is in agreement with the assumption that tempoparietal areas of both hemispheres are involved in the production and recall of the dream experience.

Direct and indirect measures of verbal relational memory following anterior temporal lobectomy

Medial temporal lobe (MTL) structures are implicated in forming conjunctions between events in order to form enduring relational memories; these memories are not evident using direct measures with varieties of amnesic subjects. Extratemporal brain structures are thought to be responsible for preserved memories, which are sometimes detectable using indirect measures. The present study tests this theory of multiple memory systems by examining whether preserved learning can be demonstrated for relational material in MTL-disordered subjects using an indirect measure which minimises conscious mediation of performance. The subjects had undergone anterior temporal lobectomy for relief of temporal lobe epilepsy: left-sided (LATL) cases had a mild verbal amnesia and right-sided (RATL) cases had better verbal memory, forming a comparison group. A direct measure of verbal relational memory was provided by successive trials of cued recall in a specially-constructed paired associate learning task with arbitrarily paired words; pairs consisted of either concrete or abstract words. LATL subjects performed worse than RATL subjects, and particularly so with abstract words. Following direct testing, memory for the pairings was measured indirectly using a masked recognition priming technique. RATL subjects showed savings in RT, demonstrating that masked priming can reveal evidence of the formation of conjunctions. Critically, LATL subjects showed no evidence of preserved learning with priming. Thus when MTL structures are damaged, relational memory appears to be affected without exception, consistent with the tenets of multiple memory systems theory.

Social communication in children with epilepsy

BACKGROUND

This study examined measures of social communication that involve the use of language in formulating and organizing thoughts and its relationship with seizure-related, developmental, cognitive, and behavioral variables in 92 children with complex partial seizure disorder (CPS), 51 with primary generalized epilepsy (PGE), and 117 normal children, aged 5.1-16.9 years.

METHODS

Coding the children's speech samples with the Kiddie Formal Thought Disorder Rating Scale (Caplan et al., 1989) and Halliday and Hasan's (1976) analysis of cohesion demonstrated social communication deficits in both seizure disorder groups.

RESULTS

The CPS patients had both formal thought disorder and cohesion deficits and the PGE group had mild cohesion deficits. IQ, as well as fronto-temporal and bilateral spike and wave activity were associated with the severity of the social communication deficits of the CPS group. The social communication deficits of the PGE group, however, were related to IQ and seizure control.

CONCLUSIONS

Recurrent CPS and PGE and fronto-temporal localization of epileptic activity might impair the development of children's communication skills.

The use of a skill-based activity in therapeutic induction

This paper describes a hypnotherapeutic intervention for a brain damaged 36-year-old male who has suffered from asthma since infancy and seizure disorder from the age of eight. In early sessions it was discovered that conventional "passive-relaxation" induction techniques seemed to exacerbate certain disturbing somatic experiences, which he refers to as scary feelings. It was found that his performance of a previously learned skilled activity (the playing of the computer game Tetris) permitted the experience of a highly focused but relaxed state that was conducive to therapeutic interaction. This approach to induction bears similarity to "active-alert" procedures but may be more importantly related to Mihaly Csikszentmihalyi's principle of flow, in that it involves engagement in a subjectively meaningful, skill-based activity.

The short-term impact of adjunctive tiagabine on health-related quality of life

Combinations of tiagabine (TGB), carbamazepine (CBZ), and phenytoin (PHT) were compared for their impact on health-related quality of life (HRQOL) and adverse effects related to treatment efficacy for people with frequent complex partial seizures. Two independent, randomized, double-blind clinical trials for efficacy and safety were conducted simultaneously with treatment groups: CBZ+PHT versus CBZ+TGB, and PHT+CBZ versus PHT+TGB. Treatment was initiated at week 0 and continued through week 16. HRQOL was evaluated with the QOLIE-89. Treatment success was defined as > or =50% reduction in complex partial seizures. Among patients who achieved a > or =50% reduction in seizures, addition of TGB to baseline PHT enhanced patient perceptions of attention/concentration (13%; p = 0.002), memory (17%; p = 0.042), and language subscales (22%; p = 0.004). Addition of CBZ to PHT led to positive change in the work/driving/social relations subscale (14%; p = 0.004). These improvements were significantly different only between visits, not between the two treatment groups. Seizure worry subscale scores showed improvement among all treatment groups and was probably related to participation in the clinical trial. These exploratory analyses suggest a possible early positive effect of TGB on patient-perceived cognitive domains using the QOLIE-89. These findings are limited by the small sample size and could be related to reduction in seizures.

Complex partial epileptic-like experiences in university students and practitioners of Dharmakaya in Thailand: comparison with Canadian university students

We tested the hypothesis that individuals who frequently practice meditation within another culture whose assumptions explicitly endorse this practice should exhibit more frequent and varied experience associated with complex partial epilepsy (without the seizures) as inferred by the Personal Philosophy Inventory and Roberts' Questionnaire for the Epileptic Spectrum Disorder. 80 practitioners of Dharma Meditation and 24 university students in Thailand were compared with 76 students from first-year courses in psychology in a Canadian university. Although there were large significant differences for some items and clusters of items expected as a result of cultural differences, there were no statistically significant differences between the two populations for the proportions of complex partial epileptic-like experiences or their frequency of occurrence. There were no strong or consistent correlations between the history of meditation within the sample who practiced Dharma meditation and these experiences. These results suggest complex partial epileptic-like experiences may be a normal feature of the human species.

Measures of psychopathology in children with complex partial seizures and primary generalized epilepsy with absence

OBJECTIVE

This investigation examined psychopathology in 48 children with complex partial seizures (CPS), 39 children with primary generalized epilepsy with absence (PGE), and 59 nonepileptic children, aged 5 to 16 years, by comparing the Child Behavior Checklist (CBCL) and the Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS).

METHOD

The CBCL was completed by parents and the K-SADS was administered to both parent and child.

RESULTS

The CBCL identified psychopathology in 26% and the K-SADS in 51% of the CPS and PGE patients (kappa = 0.32). The CPS and PGE groups had significantly higher mean CBCL scores, as well as higher rates of psychiatric diagnoses and symptoms of psychopathology, compared with the nonepileptic group. However, the CPS and PGE groups did not differ in these measures. Within each patient group, Full Scale IQ, but not seizure control, was associated with these measures of psychopathology.

CONCLUSION

These findings suggest that the K-SADS identifies more children with psychopathology than the CBCL in children with CPS and PGE.

Synchronized feeding as a "conditioned stimulus" for overt seizures in chronically (limbic) epileptic rats: a model for "psychogenic seizures" with complex partial epilepsy

Chronic limbic epilepsy was induced in male albino rats by a single systemic injection of lithium (3 mEq/kg) and pilocarpine (30 mg/kg). During the subsequent months the numbers of spontaneous, paroxysmal stereotyped episodes (analogous to Racine stages 4 and 5) were monitored. The numbers of these "overt seizures" increased within 10 min of the daily presentation of a food stimulus even though food was available ad libitum. The majority of the paroxysmal, stereotyped behaviours occurred within 1 min of the stimulus presentation; they were attenuated by oral prednisolone. Three rats displayed evidence of "conditioned seizures" to specific stimuli. The results suggest that the display of these behaviours can be synchronized and learned in contexts that are associated with the release of CRF (corticotrophin releasing factor) and may involve the disinhibited activity within the central amygdaloid nucleus of these rats. Implications for the occurrence of psychogenic seizures in patients with complex partial (limbic) epilepsy are discussed.

A pilot study on benign partial epilepsy in children with complex partial seizures

In a review of 145 children with partial onset epilepsy, the authors were able to determine a focus of children whose complex partial seizures (CPS) ran a benign course, who had no identifiable lesion on scanning and whose EEG focus was not fixed, but tended to shift. The authors suggest that a benign form of CPS in children can be recognised.

Symptomatic or cryptogenic partial epilepsy of childhood onset: fourteen-year follow-up

This study reports on the seizure and psychosocial outcome of 29 patients with electroclinically well-defined childhood-onset symptomatogenic or cryptogenic partial epilepsy with complex partial seizures who were followed prospectively over 14 years. Many were refractory at the time of enrollment. At 14-year follow-up, we acquired information on seizure type and frequency, psychiatric history, substance abuse, criminal activity, in addition to educational, vocational, and marital status through chart reviews and/or structured telephone interviews. Sixteen patients were only treated medically. They were divided by their following responses to medications: eight patients with less than one seizure per month were in the medically responsive group and eight patients with at least one seizure per month constituted the medically refractory group. Thirteen patients underwent focal resection for medically refractory epilepsy. Medically refractory patients displayed worse educational, vocational, social, and behavioral outcomes than medically responsive patients. Behavioral abnormalities persisted or evolved in five medically refractory patients when they became seizure free. Other studies have indicated that patients with medically refractory complex partial seizures have poor psychosocial outcomes. Although behavioral problems can occur even when seizures are well controlled, their early detection and treatment may be essential to the improvement of psychosocial outcomes.

Patterns of memory performance in children with controlled epilepsy on the CVLT-C

Decreased memory skills have been reported in children with epilepsy. However, standardized instruments to evaluate learning and memory in children have been unavailable until recently. The present study was designed to assess memory patterns in children with epilepsy based on the California Verbal Learning Test-Children's Version (CVLT-C). The test was administered to 44 children with complex partial seizures and 21 children with generalized seizures between 8 and 13 years of age. Children in the study had been treated for epilepsy for at least 6 months, had well-controlled seizures on monotherapy, and had no evidence of anticonvulsant toxicity. Children with head injuries, learning disabilities, or hyperactivity were excluded. Test results did not reflect differences in memory performance based on seizure type. Scores for the entire sample indicated intact new learning, decreased intrusions and perseverative responses, and better short-term than long-term delayed recall. Recognition skills were stronger than long-term delayed recall skills and suggested that memory performance may be improved for these children when a multiple-choice format is available in academic settings.

Vagus nerve stimulation is associated with mood improvements in epilepsy patients

Vagus nerve stimulation (VNS) has gained increasing acceptance for treatment of drug-resistant seizures. The aim of this study was to evaluate effects of VNS on depressed mood in epilepsy patients during the first 6 months after implantation of the stimulation device. This study was conducted as an addition to the international multisite randomized and double-blind controlled trial on anti-seizure effects of VNS (EO3). Only adult patients with >4/month medication-resistant complex-partial seizures were included (N=11). During the acute phase of the study (3 months after implantation), patients were randomly assigned to low (stimulation detection) versus high stimulation (maximal tolerability, maximum 1.75 mA). Mood and mood changes were recorded based on standardized psychiatric rating scales and self-report questionnaires. Patients were assessed 4 weeks before (baseline) as well as 3 and 6 months after implantation. Significant positive mood effects were observed in most scales and subscales at the 3-month follow-up (P<0.05). Mood improvements were sustained at the 6-month follow-up and were independent of effects on seizure activity (9/11 mood responders versus 2/11 seizure responders). Mood effects appeared more pronounced in the high stimulation group after the acute study phase, but findings were not significant (P<0.10). VNS is associated with mood improvements in patients with epilepsy, but to confirm VNS dose effects, studies with more statistical power are needed.

Tiagabine versus phenytoin and carbamazepine as add-on therapies: effects on abilities, adjustment, and mood

The effects of tiagabine (TGB) on abilities and on adjustment and mood are as yet incompletely understood. These effects were compared with those of phenytoin (PHT) and carbamazepine (CBZ) in an add-on study. Patients included in the analysis were adults with uncontrolled partial seizures who at study entry were on CBZ alone (n=153) or on PHT alone (n=124). Of the patients receiving CBZ, 82 were randomized to add-on TGB and 71 were randomized to add-on PHT during the double-blind period. Of the patients receiving PHT, 58 were randomized to add-on TGB and 66 were randomized to add-on CBZ. Eight tests of mental abilities and three of mood and adjustment were given prior to assignment of add-on treatment and after up to 16 weeks of add-on treatment. For the baseline CBZ group, analyses were done to search for differential changes from baseline in the test scores of the add-on TGB and add-on PHT groups, and for the baseline PHT group in the add-on TGB and add-on CBZ groups. In the baseline CBZ group, no differences in test scores were found between PHT and TGB. In the baseline PHT group for the area of abilities, patients treated with TGB had improved verbal fluency, as well as quicker responses on a test of perceptual/motor speed compared with patients treated with CBZ. For the baseline PHT group in the area of adjustment and mood, patients treated with TGB reported less positive mood and more financial concerns compared to patients treated with CBZ. Overall, add-on TGB showed few or no differences in comparison with add-on CBZ and add-on PHT.

No, some types of nonconvulsive status epilepticus cause little permanent neurologic sequelae (or: "the cure may be worse than the disease")

Nonconvulsive status epilepticus (NCSE) is characterized by a cognitive or behavioral change which lasts for at least 30 minutes, with EEG evidence of seizures. Although there is little argument that generalized nonconvulsive status epilepticus (GNSE) does not cause lasting deficits, there is still debate regarding the morbidity of complex partial status epilepticus (CPSE). Because the EEG is used for diagnosis, a strong argument can be made that NCSE is significantly under-recognized and diagnosed. Furthermore, since the documented cases of permanent neurologic sequelae are few, the potential permanent morbidity from CPSE may be significantly exaggerated. The literature indicates that comatose patients have a poor prognosis largely as a result of comorbid conditions and coma, whereas lightly obtunded or slightly confused patients with NCSE have little or no sequelae. Patients with NCSE may suffer (hypotension and respiratory suppression) from iatrogenic 'aggressive' treatment with intravenous anti-epileptic drugs (IV-AEDs), and the findings in the literature indicate that subjects treated with benzodiazepines may have a worse prognosis. The clinician must balance the potential but rare neurologic morbidity associated with NCSE against the not infrequent morbidity caused by IV-AEDs. Better stratification of the level of consciousness and comorbid conditions is needed when evaluating outcomes so as to clearly distinguish among the deficits due to: comorbid conditions; the effects of treatment and the effects of status epilepticus (SE) proper.

Behaviors induced or disrupted by complex partial seizures

We reviewed the neural mechanisms underlying some postictal behaviors that are induced or disrupted by temporal lobe seizures in humans and animals. It is proposed that the psychomotor behaviors and automatisms induced by temporal lobe seizures are mediated by the nucleus accumbens. A non-convulsive hippocampal afterdischarge in rats induced an increase in locomotor activity, which was suppressed by the injection of dopamine D(2) receptor antagonist in the nucleus accumbens, and blocked by inactivation of the medial septum. In contrast, a convulsive hippocampal or amygdala seizure induced behavioral hypoactivity, perhaps by the spread of the seizure into the frontal cortex and opiate-mediated postictal depression. Mechanisms underlying postictal psychosis, memory disruption and other long-term behavioral alterations after temporal lobe seizures, are discussed. In conclusion, many of the changes of postictal behaviors observed after temporal lobe seizures in humans may be found in animals, and the basis of the behavioral change may be explained as a change in neural processing in the temporal lobe and the connecting subcortical structures.