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The Neuropsychiatry of Epilepsy
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Book description

Research into the neuropsychiatry of epilepsy has become a central focus of interest in the last five years. Comorbidity of epilepsy with behavioral problems is now recognized widely, and the neuroscientific basis for such comorbidity is an active area of investigation. With an expanded international team of authors, this fully revised new edition builds on the strengths of its predecessor, examining in detail the subtleties of behavioral changes in patients with seizure disorders and offering both a diagnostic and a management perspective. New chapters cover genetic disorders, the effects of epilepsy on social behavior as viewed through theory of mind, a discussion of the precuneus, the importance and nature of peri-ictal psychiatric symptoms, depression and the interictal dysphoric disorder, and the relationship between antiepileptic drugs and suicide. This new edition is a must for anyone involved in diagnosing or managing epilepsy.

Reviews

Review of the first edition:'I find [this book] a valuable resource and reference book on a topic for which there are few sources of similarly well-organized, up-to-date information and recommend it.'

Source: Annals of Neurology

Review of the first edition:'Extremely well written and edited, the production of the book is well above average. Congratulations to the editors and the authors for providing a state-of-the-art picture of a complex topic like epilepsy. This book should be on the bookshelf of every clinician whether they deal directly with epilepsy or not.'

Source: International Review of Psychiatry

Review of the first edition:'The editors did an excellent job in putting together such a broad and complex topic for clinicians treating epilepsy patients … a must for all neurologists, psychiatrists, and neuropsychiatrists involved in treating epileptic patients and their behavioral disorders.'

Source: Doody's Electronic Journal

Review of the first edition:'… the book is highly informative on a variety of areas … In my office, I have three shelves above my desk. The lowest shelf contains books that I access regularly when a clinical question arises. This book will sit on that shelf.'

Source: British Journal of Psychiatry

'… significantly updated … and addresses many new topics … an excellent resource … The second edition is even better than the first, and should be required reading for all neurologists and psychiatrists.'

Source: Doody's Notes

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Contents

  • Chapter 7 - Peri-ictal psychiatric phenomena
    pp 57-66
  • View abstract

    Summary

    This introduction presents an overview of the concepts discussed in this book The Neuropsychiatry of Epilepsy. In the intervening years, there has been a clear appreciation in biological psychiatry of the neurobiological bases of psychopathologies as major depressive disorder, obsessive-compulsive disorder and other anxiety-related conditions, and there has been further development of psychotropic and anticonvulsant drugs (AEDs). The second edition starts with epidemiology, which has become a prominent discipline in research attempting to disentangle the extent and variety of psychiatric comorbidities in epilepsy. The clinical presentations and the wide spectrum of peri-ictal disorders are then discussed. Depression in epilepsy may not be quite like depression in the absence of epilepsy, the neuroanatomy giving a special stamp on the phenomenology. The book concludes with a discussion on the brain mechanisms of consciousness as may be revealed through investigations of patients with seizure disorders.
  • Chapter 8 - Postictal psychoses: established facts and new clinical questions
    pp 67-79
  • View abstract

    Summary

    Most studies examining the comorbidity of epilepsy and psychiatric disorders have been cross-sectional in hospital- and institution-based populations. This chapter summarizes community-based studies of psychiatric comorbidity in epilepsy. While cross-sectional studies of psychiatric disorders and epilepsy provide valuable public health information and inform epileptologists and psychiatrists, they have significant limitations. Over the past 20 years, a body of work has emerged examining whether specific psychiatric disorders are associated with an increased risk for developing epilepsy, and assessing the incidence of psychiatric disorders after the onset of epilepsy. Attention-deficit hyperactivity disorder (ADHD) and depression is associated with an increased risk for developing epilepsy. Several studies show that a history of major depression is associated with an increased risk for developing unprovoked seizures. Studies examining the time order of the relationship between psychosis or schizophrenia and epilepsy have all been conducted in population-based registries.
  • Chapter 9 - The interictal dysphoric disorder
    pp 80-89
  • View abstract

    Summary

    This chapter looks at the management of epilepsy in people with an intellectual disability, which has gained increasing importance over recent years, and the interface between the genotype causing the intellectual disability and potential behavioral and epilepsy phenotypes associated with this genotype. It uses a working definition of the pattern of seizure type, seizure syndrome and treatment response characterized by a specific genotype. An evaluation of a population of individuals with an intellectual disability, or global developmental delay, is likely to yield a potential diagnostic category in approximately 40-60%. The prevalence of epilepsy amongst the population of people with an intellectual disability varies between studies from as low as 13% to as high as 40%. The chapter also gives some examples of common genetic causes of intellectual disability, and outlines the physical, behavioral, and epileptic phenotypes associated with them.
  • Chapter 10 - Behavioral and neuropsychological aspects of frontal and temporal lobe epilepsy
    pp 90-108
  • View abstract

    Summary

    Autism, mainly affecting social interaction and verbal and nonverbal communicative functions, is not a single disease, and can be associated with different brain disorders. This chapter focuses on epileptic syndromes or types of epilepsies in which autistic symptoms can be a predominant manifestation, and can worsen or improve in direct correlation with the activity of the epilepsy, even though they probably constitute a minority of situations in which both autism and epilepsy co-occur. The structures of the limbic system thought to be involved in autistic spectrum disorders (ASD) are highly epileptogenic and are the origin of frequently encountered early childhood epilepsies or epileptic syndromes. There are numerous paroxysmal nonepileptic neurological disorders which can be erroneously diagnosed as epilepsy. The clinical diagnosis and management of autistic children and adults, while sharing the same principles as those followed with other handicapped persons, have unique features related to the specific symptoms of ASD.
  • Chapter 11 - Emotional agnosis and theory of mind
    pp 109-123
  • View abstract

    Summary

    Both cognitive and behavioral problems are common in people with epilepsy. State-dependent cognitive impairment is potentially reversible and treatable. People having frequent absence seizures may present as having withdrawn behavior, fragmented thought processes which may be mistaken for a psychosis, attention-deficit disorder with motor over activity, or, if the frequency of the seizures is variable, attention seeking behavior. It is important to be aware of the possibility of reversible, state-dependent cognitive impairment in an individual who is in a constant postictal state from frequent seizures. Reducing the seizure frequency can improve cognitive function markedly. It has become evident that a number of children who present with markedly autistic features have unsuspected epileptiform discharges either during the day or at night. If frequent epileptiform discharges are found in association with cognitive or behavioral problems then early, energetic treatment should be initiated.
  • Chapter 12 - Nonepileptic seizures
    pp 124-132
  • View abstract

    Summary

    Dementia and seizures occur in a significant proportion of patients with increasing prevalence in the elderly. This chapter reviews the epidemiology of dementia and the epidemiology of seizures in the elderly and then looks for the reported coincidence of dementia and seizures. The prevalence of epilepsy shows a similar trend; prevalence increases from approximately 55 years of age and is more than twice that of the general population by 85 years of age or more. Seizures can present in an unusual fashion, such as transient epileptic amnesia. Rarely, seizures can occur at the time of diagnosis in patients with probable Alzheimer's disease. Routine investigations should also include an electrocardiogram, complete routine blood work including electrolytes, liver enzymes, kidney function, and blood cell count. Current animal work is encouraging in the further investigation of the overlap between hyperexcitability, cognitive decline, and established dementia.
  • Chapter 13 - The effects of antiepileptic drugs on behavior
    pp 133-142
  • View abstract

    Summary

    Postictal psychiatric phenomena are relatively frequent in patients with treatment-resistant epilepsy. This chapter reviews the most relevant clinical aspects of peri-ictal symptomatology. Ictal panic is one of the most frequently misdiagnosed symptoms in medical practice, as it is often diagnosed as a panic attack. Postictal psychiatric phenomena may be the expression of isolated psychiatric symptoms; clusters of postictal psychiatric symptoms (PPS) mimicking a depressive, anxiety or psychotic episode; postictal exacerbation in severity of interictal psychiatric symptoms and persistence of interictal symptoms into the postictal period. In contrast to postictal symptoms of depression (PSD) or PDE, postictal psychotic episodes (PIPE) can be readily prevented and treated. Prevention of PIPE is possible in patients who are found to have bilateral ictal foci in the course of a video-EEG or who are known to develop PIPE after a cluster of seizures.
  • Chapter 14 - Antiepileptic drugs and suicide
    pp 143-152
  • View abstract

    Summary

    This chapter presents a short history of postictal psychosis (PIP) studies and established clinical pictures of nuclear PIP. It discusses the interrelationship between PIP and interictal psychosis (IIP), results of neuro-imaging studies of PIP, premorbid predisposition (including family history) or risk factors, and PIP-related peri-ictal phenomena including discussion of PIP subtypes. Four different combinations of PIP and IIP have been recognized: progression of PIP to chronic psychosis; PIP changing into IIP without a break during an episode of psychosis; PIP and IIP episodes occurring in an alternating manner; and PIP episodes follow after remission of IIP episodes. As with SPECT studies, only a few depth-EEG studies during active PIP episodes are available, though the results suggest interesting subtypes. Psychopathological features of PIP are highly suggestive of association with bipolar disorder, which is supported by data from different perspectives.
  • Chapter 15 - Antiepileptic drugs and cognitive disorders
    pp 153-164
  • View abstract

    Summary

    Depression in epilepsy represents a frequently encountered psychiatric comorbidity that is likely to be related to a number of variables that are both biological and psychosocial. Current literature on the neurobiology of depression in epilepsy has focused on frontal lobe dysfunction. Modern studies of interictal psychiatric disorders of epilepsy have usually attempted to identify their similarities to the psychiatric disorders that meet current classificatory systems. In the interictal dysphoric disorder, eight key symptoms, grouped in three major categories, are identified: labile depressive symptoms, labile affective symptoms, and supposedly specific symptoms (paroxysmal irritability and euphoric moods). A specific instrument, named Interictal Dysphoric Disorder Inventory (IDDI), has been developed in the context of a collaborative German-Italian study. One of the most frequent methodological errors in studies of depression in epilepsy is the sole reliance on screening instruments for the diagnosis of depressive disorders.
  • Chapter 16 - Psychiatric illness and psychotropic medication use in epilepsy
    pp 165-196
  • View abstract

    Summary

    To date neurobiological interest in the behavioral consequences of epilepsy has been concerned primarily with the neuropsychology of temporal lobe epilepsy (TLE) and of mesial temporal lobe epilepsy (mTLE) in particular. In epilepsy several factors can be discerned, which can lead to dynamic and principally reversible changes in the patient's behaviors and mood states. The patient with epilepsy must always be seen in his or her state relative to seizures. Epileptic activity can affect distant brain areas and cause cognitive and behavioral problems beyond the primary lesion. Antiepileptic drugs may have positive or negative psychotropic side effects, and can show incompatibilities in the individual patient. Very special behavioral and neuropsychological conditions are met during nonconvulsive status epilepticus (NCSE). The chapter concludes that in temporal and frontal lobe epilepsy dysfunctional behaviors can be discerned which characteristically correspond to the affected brain regions.
  • Chapter 17 - Psychiatric effects of surgery for temporal lobe epilepsy
    pp 197-208
  • View abstract

    Summary

    Imaging and lesion studies have identified cerebral networks associated with social cognitive functions which are frequently affected in patients with temporal or frontal lobe epilepsies. Processing of emotional information plays an important role in many aspects of cognition, including decision-making, memory, and attention. The perception and expression of emotional information and theory of mind (ToM) abilities have been investigated in numerous studies in a variety of patient groups and healthy persons using a number of experimental paradigms and tests. The chapter presents short descriptions and behavioral data from a variety of tests in order to reveal their differences and to highlight recent developments and research perspectives. Mesial temporal lobe epilepsy (MTLE) is the most prevalent focal epilepsy. Structure-function analyses have also shown an association between impairments in the recognition of facial expressions, especially of fear and reduced fMRI activity in patients with early onset right-sided TLE.
  • Chapter 18 - Brain mechanisms of impaired consciousness in epilepsy
    pp 209-220
  • View abstract

    Summary

    Psychogenic nonepileptic seizures (PNES) are paroxysms of altered bodily/mental function. Careful history-taking can elicit most risk factors for PNES. Comorbid psychiatric diagnoses including depression, anxiety, and personality disorder, and family history of psychiatric disorders are also PNES risk factors. Seizure semiology is crucial for raising the clinician's suspicion of PNES, and is often the first step towards making the correct diagnosis. Most studies that assess seizure semiology are structured as retrospective analyses of long-term video EEG. Various prognostic indicators have been reported including clinical and psychological factors. Poorer prognosis is associated with the presence of chronic depression, an Axis II personality disorder, and a history of abuse or trauma. Clinical experience and prior-published treatment reports reveal that coordination between neurologists and psychiatrists/psychologists, with accurate diagnosis and prompt initiation of psychotherapy and communication between care providers, patient and family, yields higher treatment success.

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