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Psychiatric Implications of Surgical Treatment of Epilepsy
Psychiatric Implications of Surgical Treatment of Epilepsy LOIS
E.
KRAHN,
M.D., TERESA A. RUMMANS, M.D., AND GERALD C.
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 psy-
Surgical treatment of epilepsy is increasingly used in patients with medically refractory seizure disorders. The selection of patients for neurosurgical intervention is a critical issue because of the irreversible nature of the procedure. Patients who ultimately become free of seizures have an easier postoperative adjustment because seizures no longer complicate their overall medical management. In this article, we address the issues relevant to the immediate postoperative period and review the effect of psychotic, mood, anxiety, and other psychiatric disorders in this group of patients. IMMEDIATE POSTOPERATIVE PERIOD Psychiatric symptoms, ranging from agitation to somnolence to psychosis to dysphoria, that emerge during the 2 weeks after surgical treatment of epilepsy need to be examined separately because of confounding issues such as postoperative high-dose corticosteroids, barbiturates, seizures, cerebral edema, and anesthetic agents. Any of these factors can induce a delirious state that is distinct from other psychiatric conditions existing preoperatively or postoperatively. We know of no published case reports of psychiatric problems during the immediate postoperative period; in our experience, however, postoperative delirium has developed in rare From the Department of Psychiatry and Psychology (L.E.K., T.A.R., G.C.P.), Mayo Clinic Rochester, Rochester, Minnesota. *Emeritus staff. Individual reprints of this article are not available. The entire Symposium on Epilepsy will be available for purchase as a bound booklet from the Proceedings Circulation Office at a later date. Mayo Clin Proc 1996; 71:1201-1204
PETERSON,
M.D. *
chotic 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. (Mayo Clin Proc 1996; 71:1201-1204)
cases. The risk factors for occurrence of delirium after surgical treatment of epilepsy are unknown. Often the exact cause cannot be delineated, and treatment is initiated on an empirical basis. The patient with delirium must first be carefully assessed for evidence of ongoing seizure activity-which, if present, demands aggressive treatment. Treatment must be initiated urgently because in an agitated state the patient can pull out the peripheral lines necessary for anticonvulsant medications or can open the surgical incision. At our institution, treatment consists of removing any triggering factor (for example, high-dose corticosteroids), reducing noxious environmental stimuli, and, if warranted, applying physical restraints. Generally, both benzodiazepines and antipsychotic agents are administered. Medications such as lorazepam (administered intramuscularly or intravenously) can provide prompt sedation and protection against seizures; antipsychotic agents such as haloperidol (given intramuscularly or intravenously) can eventually normalize the patient's misperceptions. Except for close surveillance for seizures, the management of delirium after operative intervention for epilepsy in our practice does not differ appreciably from treatment of acute confusional states after other surgical procedures. PSYCHOTIC DISORDERS Distinguishing between interictal and postictal psychotic symptoms is important clinically because patients with the former disorder require more continuous treatment with antipsychotic medications. The prevalence of chronic interictal psychoses such as schizophrenia is believed to
1201
© 1996 Mayo Foundation/or Medical Education and Research
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
1202 PSYCHIATRIC DISORDERS AND TREATMENT OF EPILEPSY
Mayo Clio Proc, December 1996, Vol 71
approach 9% for persons with epilepsy in comparison with tors are conducive to surgical intervention, patients with I% in the general population. I Patients with epilepsy who exclusivel y postictal psychotic symptoms often are good have chronic psychotic disorders are less common in the surgical candidates, inasmuch as becoming free of seizures surgical population because of referral patterns.' The eliminates the trigger for their psychotic symptoms.' Not all interictal psychotic symptoms can dim inish with remission patients will have remission of their psychotic symptoms; of seizures postoperatively, although the goal should be publi shed studies have suggested that 3% of these patients improved control of the seizure disorder and not remission of have persistent seizures and postictal psychosis," For pathe psychotic disorder.' Rate s of preoperative chronic psy- tients who do not become free of seizures postoperatively , chosis reported in studies between 1962 and 1984 ranged the risk of de novo postictal psychosis exists. In one study of from 7 to 16%, and the psychosis persisted postoperatively 298 patients, Manchanda and associates? reported a 1% rate in 6 to 15%.4 In a large surgical sample, chronic psychotic of new cases of postictal psychosis during the first year disorders have been associated with prenatal or perinatal postoperatively; they believed that patients with persistent brain lesions, lesions in the median temporal lobe, ganglio- seizures after undergoing right temporal lobectomy had an glioma s, left-sided lesions, and early age at onset of sei- increased risk for psychosis. If postoperative seizures are zures.' The patients with psychotic symptoms that persisted infrequent, treatment includes use of antipsychotic medications on a short-term basis. For patients with frequent seipostoperatively tended to have bilateral seizure foci." Patients with chronic interictal psychotic disorders should zures leading to long-term postictal psychosis, continuous be stabilized with medication and psychosocial interventions use of antipsychotic agent s may be necessary. before surgical treatment of epilepsy is seriously considered. Such interventions are particularly important for this group MOOD DISORDERS of patients because untreated paranoia or hallucinations can Similar to the overall population of patients with epilepsy, cause noncompliance with follow-up care . Treatment of those selected for surgical treatment have higher rates of patients with chronic psychotic disorders should emphasize preoperative depressive disorders than do surgical candiantipsychotic medications with the lowest risk of inducing date s in the general population. In one recent study,'? the seizures. Recommended agents are high -potency anti - lifetime prevalence of all depressive disorders (as officially psychotic drugs such as haloperidol or the newer atypical categorized by the American Psychiatric Association) has agent risperidone. Clinicians should discern whether the been reported as 62% and of major depression as 30%patient has psychotic symptoms aUributable to a severe de- con siderably higher than the rates in the general population. pressive disorder. Treatment with a combination of an anti- Patients with left temporal lobe hypometabolism measured depressant and an antipsychotic medication or with electro- with positron emission tomography had an increased likelihood of having recurrent major depression. The point prevaconvulsive therapy may be indicated. In a few patients, a new-onset chronic psychotic disorder lence of depressive disorders immediately preoperatively develops postoperatively. A survey of 26 epilepsy surgical has not been thoroughly studied. To date, little is known treatment centers conducted between 1986 and 1989 found a about the predictive significance of a current or a lifetime rate of new-onset postoperative chronic psychosis of 0.4 %.7 history of major depression or other depressive disorders Rate s in reports published between 1962 and 1984 ranged relative to postoperative complications. from 0.5 to 21%.4 This wide range of rates is explained, in Treatment of depression before surgical intervention for part , by variations in surgical indications, psychiatric diag- epilepsy is desirable because the depressive symptoms can nostic criteria, and sample sizes. In our experience, the compromise the patient 's ability to comply with postoperafrequency of de novo postoperative psychotic disorders tive rehabilitation. Preoperative treatment can include the seems most consistent with the lower rates. In comparison same modalities proposed for postoperative depression. Pawith recent reports, the older literature tends to present a tients with less severe depressive symptoms have tolerated more pessimistic outlook for patients in whom psychotic surgical treatment of epilepsy without specific problems. No disorders develop postoperatively. When chronic psychotic studie s have found that patients with preoperative depressive symptoms emerge postoperatively, patients should recei ve disorders are at higher risk of postoperative psychiatric long-term treatment with antipsychotic medications and complications. Depressive disorders are believed to be the most common psychosocial intervention. The link between seizures and psychosis has generated postoperative psychiatric problem. II A postoperative study considerable interest because, infrequently, postictal psy- with 6-month follow-up described a prevalence rate for tranchosis can be a distressing symptom of epilepsy. The preva- sient depression of 34%.12 A second study with 12-month lence of postictal psychosis in samples of patients selected follow-up reported a rate of 9%, with most cases occurring in for surgical treatment is unknown. If other neurologic fac- patients who had not had depression preoperatively. I I AI-
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
Mayo Clio Proc, December 1996, Vol 71
though numerous possible risk factors have been examined, including cerebral dominance and histopathologic features, no association has been convincingly established. No published reports have described mania evolving after surgical treatment of epilepsy, but in our clinical experience, this transient mood elevation has been encountered rarely and resolved without intervention. Many treatment options are available for patients with depression postoperatively. Supportive psychotherapy or cognitive-behavioral therapy can assist a patient with the transition from a lifestyle in which frequent seizures preclude many activities to a situation in which opportunities and expectations are perhaps overwhelming. Antidepressant medications with minimal effect on the seizure threshold, such as the selective serotonin reuptake inhibitors, are the logical choices even though patients typically receive anticonvulsant medications for I year postoperatively as a prophylactic measure. Electroconvulsive therapy has been safely and effectively used for a patient with severe psychotic depression 1 year after surgical treatment of epilepsy.!' Depression emerging postoperatively seems as responsive to treatment as other cases of depression, although no published studies have specifically addressed this issue.
ANXIETY DISORDERS Most likely because they are viewed as less severe and debilitating than other psychiatric disorders, minimal attention has been paid to anxiety disorders in patients undergoing surgical treatment of epilepsy. Nonetheless, because anxiety symptoms can mimic auras and ictal symptoms, these disorders are clinically significant. Severe anxiety disorders are not benign, as demonstrated by epidemiologic data that 18% of patients with panic disorder attempted suicide during their lifetime in comparison with 1% of the general population." Preoperatively, the prevalence of anxiety disorders is high in comparison with that in healthy control subjectsreported rates of 28% versus 16% for phobia and of 8% versus 0% for panic disorder. No differences were noted in the prevalence of obsessive-compulsive disorder." How patients with anxiety disorders tolerate surgical treatment of epilepsy is unclear. A prudent approach is to treat patients with distressing anxiety symptoms before proceeding to the stressful experience of a neurosurgical procedure. Usually, surgical candidates can be stabilized with the short-term use of a benzodiazepine. Few psychiatric follow-up studies after surgical treatment of epilepsy have included anxiety disorders. In one study that addressed this issue, Bladin" found that 58 of 115 consecutive patients (50%) experienced transient anxiety postoperatively. Short-term hospitalization was used in 17
PSYCHIATRIC DISORDERS AND TREATMENT OF EPILEPSY
1203
cases (15%). Preoperatively, 44% of this sample of patients had anxiety. For unclear reasons, postoperative anxiety was significantly associated with left-sided lesions. The author suspected but could not prove that abrupt termination of long-term treatment with benzodiazepine anticonvulsants such as clonazepam was a factor. In some cases, anxiety decreases postoperatively. A published case" described the remission of obsessive-compulsive disorder after a right temporal lobectomy for refractory partial seizures. The authors speculated that this points to an organic cause for the severe anxiety disorder.
NONEPILEPTIC SEIZURES Nonepileptic seizures, also known as pseudoseizures, occasionally coexist with epileptic seizures in some patients. The medical and psychiatric differential diagnosis of nonepileptic spells is discussed in another article in this symposium." A dilemma arises when patients with nonepileptic events attributed to a psychiatric cause meet the neurologic criteria for surgical treatment of epilepsy because these patients may be at risk for persisting nonepileptic events even if free of epileptic seizures. A Mayo case series examined a small group of patients with postoperative nonepileptic seizures, some of whom also had preoperative somatoform symptoms." Patients at risk were found to have a longer duration of epilepsy, lower full-scale IQ, inadequate coping strategies, poor coping skills, and an overall tendency to somatize-findings that indicate postoperative psychosocial adjustment may be difficult. Patients with nonepileptic seizures who are otherwise appropriate candidates for surgical treatment of epilepsy should receive therapy for the nonepileptic episodes before undergoing a neurosurgical procedure. Ideally, the nonepileptic spells can be eliminated before surgical intervention. Treatment at our institution varies, depending on the patient's psychiatric diagnosis. Nonepileptic events associated with depressive or panic disorder can be managed with antidepressants or sedative-hypnotic agents; those associated with conversion disorder are managed with behavioral or cognitive therapy. Although most patients are treated on an outpatient basis, selected patients with severe or frequent spells have required inpatient treatment. Once the patient's condition has been stabilized, a surgical procedure can be reconsidered with the prospects of a better psychiatric outcome. OTHER DISORDERS Preoperatively, excessive use of caffeine may contribute to seizure refractoriness and anxiety disorders." At our institution, patients are advised to reduce their consumption of caffeine to a maximum of the equivalent of three cups of caffeinated coffee daily.
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
1204 PSYCHIATRIC DISORDERS AND TREATMENT OF EPILEPSY
The concept of the "temporal lobe epilepsy personality" has been debated for years. This label describes a group of patients with epilepsy who have hypergraphia, preoccupation with philosophical matters, and reduced interest in sexual matters." Although the debate continues, several studies have found no differences between such patients and other groups of psychiatric and neurologic patients.F-" No studies have examined this syndrome in candidates for surgical treatment of epilepsy, and at our institution, we do not screen for this constellation of symptoms. CONCLUSION No psychiatric factors are absolute contraindications to surgical treatment of epilepsy. The decision to proceed with operative intervention must be based on the patient's epilepsy history and neurologic factors. The main goals should be decreased frequency and severity of the patient's seizures. Attaining these goals, especially if the patient becomes free of seizures, will enhance the patient's possibility of improvement in other respects. Clearly, the approach of identifying and stabilizing psychiatric symptoms preoperatively is preferable. Especially with chronic psychotic disorders, reduction of the psychiatric symptoms should not be the primary objective of surgical treatment. The paucity of adverse reports in the setting of more widespread use of the operative management of epilepsy gives the impression that unsatisfactory psychiatric outcomes are rare. In the experience of our institution and others, most patients with epilepsy, with or without a history of psychiatric disorders, tolerate a surgical procedure well and report a substantially improved postoperative quality of life. 16
Mayo Clin Proc, December 1996, Vol 71
5. 6.
7.
8. 9. 10. II.
12. 13. 14. 15. 16. 17.
18. REFERENCES 1. Mendez MF, Grau R, Doss RC, Taylor JL. Schizophrenia in epilepsy: seizure and psychosis variables. Neurology 1993; 43: 10731077 2. Fenwick PBe. Postscript: what should be included in a standardized psychiatric assessment? In: Engel J Jr, editor. Surgical Treatment of the Epilepsies. New York: Raven Press, 1987: 2505-2510 3. Stagno SJ, Smith ML. The presurgical workup: evaluation of psychiatric issues and informed consent. In: Luders HO, editor. Epilepsy Surgery. New York: Raven Press, 1992: 453-459 4. Savard G. Psychosis and the surgery of epilepsy. In: Luders HO, editor. Epilepsy Surgery. New York: Raven Press, 1992: 461465
19. 20. 21. 22. 23.
Roberts GW, Done OJ, Bruton C, Crow TJ. A "mock up" of schizophrenia: temporal lobe epilepsy and schizophrenia-like psychosis. Bioi Psychiatry 1990; 28:127-143 Terzian H. Observations on the clinical symptomatology of bilateral partial or total removal of the temporal lobes in man. In: Baldwin M, Bailey P, editors. Temporal Lobe Epilepsy. Springfield (IL): Charles C Thomas, 1958: 510-529 Fenwick PBC, Blumer DP, Caplan R, Ferguson SM, Savard G, Victoroff Jl, Presurgical psychiatric assessment. In: Engel J Jr, editor. Surgical Treatment of the Epilepsies. 2nd ed. New York: Raven Press, 1993: 273-290 Leinonen E, Tuunainen A, Lepola U. Postoperative psychoses in epileptic patients after temporal lobectomy. Acta Neurol Scand 1994; 90:394-399 Manchanda R, Miller H, McLachlan RS. Post-ictal psychosis after right temporal lobectomy. J Neurol Neurosurg Psychiatry 1993; 56:277-279 Victoroff n, Benson F, Grafton ST, Engel J Jr, Mazziotta rc. De-' pression in complex partial seizures: electroencephalographic and cerebral metabolic correlates. Arch Neurol 1994; 51: 155-163 Naylor AS, Rogvi-Hansen B, Kessing L, Kruse-Larsen C. Psychiatric morbidity after surgery for epilepsy: short-term follow up of patients undergoing amygdalohippocampectomy. J Neurol Neurosurg Psychiatry 1994; 57:1375-1381 Chovaz CJ, McLachlan RS, Derry PA, Cummings AL. Psychosocial function following temporal lobectomy: influence of seizure control and learned helplessness. Seizure 1994; 3:171-176 Krahn LE, Rummans TE, Peterson GC, Cascino GO, Sharbrough FW. Electroconvulsive therapy for depression after temporal lobectomy for epilepsy. Convuls Ther 1993; 9:217-219 Cox BJ, Direnfeld DM, Swinson RP, Norton GR. Suicidal ideation and suicide attempts in panic disorder and social phobia. Am J Psychiatry 1994; 151:882-887 Koch-Weser M, Garron DC, Gilley OW, Bergen 0, Bleck TP, Morrell F, et al. Prevalence of psychologic disorders after surgical treatment of seizures. Arch Neurol 1988; 45:1308-1311 Bladin PF. Psychosocial difficulties and outcome after temporal lobectomy. Epilepsia 1992; 33:898-907 Kanner AM, Morris HH, Stagno S, Chelune G, Luders H. Remission of an obsessive-compulsive disorder following a right temporal lobectomy. Neuropsychiatry Neuropsychol Behav Neurosci 1993; 6:126-129 Chabolla DR, Krahn LE, So EL, Rummans TA. Psychogenic nonepileptic seizures. Mayo Clin Proc 1996; 71:493-500 Krahn LE, Rummans TA, Sharbrough FW, Jowsey SG, Cascino GD. Pseudoseizures after epilepsy surgery. Psychosomatics 1995; 36:487-493 Krahn LE, Rummans TA, Sharbrough FW, Jowsey SG, Cascino GO. Use of caffeine in medically refractory seizure patients [letter]. Neuropsychiatry Neuropsychol Behav Neurosci 1994; 7:136 Waxman SG, Geschwind N. The interictal behavior syndrome of temporal lobe epilepsy. Arch Gen Psychiatry 1975; 32:1580-1586 Hermann BP, Riel P. Interictal personality and behavioral traits in temporal lobe and generalized epilepsy. Cortex 1981; 17:125-128 Mungas D. Interictal behavior abnormality in temporal lobe epilepsy: a specific syndrome or nonspecific psychopathology? Arch Gen Psychiatry 1982; 39: 108-111
END OF SYMPOSIUM ON EPILEPSY
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
E.
KRAHN,
M.D., TERESA A. RUMMANS, M.D., AND GERALD C.
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 psy-
Surgical treatment of epilepsy is increasingly used in patients with medically refractory seizure disorders. The selection of patients for neurosurgical intervention is a critical issue because of the irreversible nature of the procedure. Patients who ultimately become free of seizures have an easier postoperative adjustment because seizures no longer complicate their overall medical management. In this article, we address the issues relevant to the immediate postoperative period and review the effect of psychotic, mood, anxiety, and other psychiatric disorders in this group of patients. IMMEDIATE POSTOPERATIVE PERIOD Psychiatric symptoms, ranging from agitation to somnolence to psychosis to dysphoria, that emerge during the 2 weeks after surgical treatment of epilepsy need to be examined separately because of confounding issues such as postoperative high-dose corticosteroids, barbiturates, seizures, cerebral edema, and anesthetic agents. Any of these factors can induce a delirious state that is distinct from other psychiatric conditions existing preoperatively or postoperatively. We know of no published case reports of psychiatric problems during the immediate postoperative period; in our experience, however, postoperative delirium has developed in rare From the Department of Psychiatry and Psychology (L.E.K., T.A.R., G.C.P.), Mayo Clinic Rochester, Rochester, Minnesota. *Emeritus staff. Individual reprints of this article are not available. The entire Symposium on Epilepsy will be available for purchase as a bound booklet from the Proceedings Circulation Office at a later date. Mayo Clin Proc 1996; 71:1201-1204
PETERSON,
M.D. *
chotic 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. (Mayo Clin Proc 1996; 71:1201-1204)
cases. The risk factors for occurrence of delirium after surgical treatment of epilepsy are unknown. Often the exact cause cannot be delineated, and treatment is initiated on an empirical basis. The patient with delirium must first be carefully assessed for evidence of ongoing seizure activity-which, if present, demands aggressive treatment. Treatment must be initiated urgently because in an agitated state the patient can pull out the peripheral lines necessary for anticonvulsant medications or can open the surgical incision. At our institution, treatment consists of removing any triggering factor (for example, high-dose corticosteroids), reducing noxious environmental stimuli, and, if warranted, applying physical restraints. Generally, both benzodiazepines and antipsychotic agents are administered. Medications such as lorazepam (administered intramuscularly or intravenously) can provide prompt sedation and protection against seizures; antipsychotic agents such as haloperidol (given intramuscularly or intravenously) can eventually normalize the patient's misperceptions. Except for close surveillance for seizures, the management of delirium after operative intervention for epilepsy in our practice does not differ appreciably from treatment of acute confusional states after other surgical procedures. PSYCHOTIC DISORDERS Distinguishing between interictal and postictal psychotic symptoms is important clinically because patients with the former disorder require more continuous treatment with antipsychotic medications. The prevalence of chronic interictal psychoses such as schizophrenia is believed to
1201
© 1996 Mayo Foundation/or Medical Education and Research
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
1202 PSYCHIATRIC DISORDERS AND TREATMENT OF EPILEPSY
Mayo Clio Proc, December 1996, Vol 71
approach 9% for persons with epilepsy in comparison with tors are conducive to surgical intervention, patients with I% in the general population. I Patients with epilepsy who exclusivel y postictal psychotic symptoms often are good have chronic psychotic disorders are less common in the surgical candidates, inasmuch as becoming free of seizures surgical population because of referral patterns.' The eliminates the trigger for their psychotic symptoms.' Not all interictal psychotic symptoms can dim inish with remission patients will have remission of their psychotic symptoms; of seizures postoperatively, although the goal should be publi shed studies have suggested that 3% of these patients improved control of the seizure disorder and not remission of have persistent seizures and postictal psychosis," For pathe psychotic disorder.' Rate s of preoperative chronic psy- tients who do not become free of seizures postoperatively , chosis reported in studies between 1962 and 1984 ranged the risk of de novo postictal psychosis exists. In one study of from 7 to 16%, and the psychosis persisted postoperatively 298 patients, Manchanda and associates? reported a 1% rate in 6 to 15%.4 In a large surgical sample, chronic psychotic of new cases of postictal psychosis during the first year disorders have been associated with prenatal or perinatal postoperatively; they believed that patients with persistent brain lesions, lesions in the median temporal lobe, ganglio- seizures after undergoing right temporal lobectomy had an glioma s, left-sided lesions, and early age at onset of sei- increased risk for psychosis. If postoperative seizures are zures.' The patients with psychotic symptoms that persisted infrequent, treatment includes use of antipsychotic medications on a short-term basis. For patients with frequent seipostoperatively tended to have bilateral seizure foci." Patients with chronic interictal psychotic disorders should zures leading to long-term postictal psychosis, continuous be stabilized with medication and psychosocial interventions use of antipsychotic agent s may be necessary. before surgical treatment of epilepsy is seriously considered. Such interventions are particularly important for this group MOOD DISORDERS of patients because untreated paranoia or hallucinations can Similar to the overall population of patients with epilepsy, cause noncompliance with follow-up care . Treatment of those selected for surgical treatment have higher rates of patients with chronic psychotic disorders should emphasize preoperative depressive disorders than do surgical candiantipsychotic medications with the lowest risk of inducing date s in the general population. In one recent study,'? the seizures. Recommended agents are high -potency anti - lifetime prevalence of all depressive disorders (as officially psychotic drugs such as haloperidol or the newer atypical categorized by the American Psychiatric Association) has agent risperidone. Clinicians should discern whether the been reported as 62% and of major depression as 30%patient has psychotic symptoms aUributable to a severe de- con siderably higher than the rates in the general population. pressive disorder. Treatment with a combination of an anti- Patients with left temporal lobe hypometabolism measured depressant and an antipsychotic medication or with electro- with positron emission tomography had an increased likelihood of having recurrent major depression. The point prevaconvulsive therapy may be indicated. In a few patients, a new-onset chronic psychotic disorder lence of depressive disorders immediately preoperatively develops postoperatively. A survey of 26 epilepsy surgical has not been thoroughly studied. To date, little is known treatment centers conducted between 1986 and 1989 found a about the predictive significance of a current or a lifetime rate of new-onset postoperative chronic psychosis of 0.4 %.7 history of major depression or other depressive disorders Rate s in reports published between 1962 and 1984 ranged relative to postoperative complications. from 0.5 to 21%.4 This wide range of rates is explained, in Treatment of depression before surgical intervention for part , by variations in surgical indications, psychiatric diag- epilepsy is desirable because the depressive symptoms can nostic criteria, and sample sizes. In our experience, the compromise the patient 's ability to comply with postoperafrequency of de novo postoperative psychotic disorders tive rehabilitation. Preoperative treatment can include the seems most consistent with the lower rates. In comparison same modalities proposed for postoperative depression. Pawith recent reports, the older literature tends to present a tients with less severe depressive symptoms have tolerated more pessimistic outlook for patients in whom psychotic surgical treatment of epilepsy without specific problems. No disorders develop postoperatively. When chronic psychotic studie s have found that patients with preoperative depressive symptoms emerge postoperatively, patients should recei ve disorders are at higher risk of postoperative psychiatric long-term treatment with antipsychotic medications and complications. Depressive disorders are believed to be the most common psychosocial intervention. The link between seizures and psychosis has generated postoperative psychiatric problem. II A postoperative study considerable interest because, infrequently, postictal psy- with 6-month follow-up described a prevalence rate for tranchosis can be a distressing symptom of epilepsy. The preva- sient depression of 34%.12 A second study with 12-month lence of postictal psychosis in samples of patients selected follow-up reported a rate of 9%, with most cases occurring in for surgical treatment is unknown. If other neurologic fac- patients who had not had depression preoperatively. I I AI-
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
Mayo Clio Proc, December 1996, Vol 71
though numerous possible risk factors have been examined, including cerebral dominance and histopathologic features, no association has been convincingly established. No published reports have described mania evolving after surgical treatment of epilepsy, but in our clinical experience, this transient mood elevation has been encountered rarely and resolved without intervention. Many treatment options are available for patients with depression postoperatively. Supportive psychotherapy or cognitive-behavioral therapy can assist a patient with the transition from a lifestyle in which frequent seizures preclude many activities to a situation in which opportunities and expectations are perhaps overwhelming. Antidepressant medications with minimal effect on the seizure threshold, such as the selective serotonin reuptake inhibitors, are the logical choices even though patients typically receive anticonvulsant medications for I year postoperatively as a prophylactic measure. Electroconvulsive therapy has been safely and effectively used for a patient with severe psychotic depression 1 year after surgical treatment of epilepsy.!' Depression emerging postoperatively seems as responsive to treatment as other cases of depression, although no published studies have specifically addressed this issue.
ANXIETY DISORDERS Most likely because they are viewed as less severe and debilitating than other psychiatric disorders, minimal attention has been paid to anxiety disorders in patients undergoing surgical treatment of epilepsy. Nonetheless, because anxiety symptoms can mimic auras and ictal symptoms, these disorders are clinically significant. Severe anxiety disorders are not benign, as demonstrated by epidemiologic data that 18% of patients with panic disorder attempted suicide during their lifetime in comparison with 1% of the general population." Preoperatively, the prevalence of anxiety disorders is high in comparison with that in healthy control subjectsreported rates of 28% versus 16% for phobia and of 8% versus 0% for panic disorder. No differences were noted in the prevalence of obsessive-compulsive disorder." How patients with anxiety disorders tolerate surgical treatment of epilepsy is unclear. A prudent approach is to treat patients with distressing anxiety symptoms before proceeding to the stressful experience of a neurosurgical procedure. Usually, surgical candidates can be stabilized with the short-term use of a benzodiazepine. Few psychiatric follow-up studies after surgical treatment of epilepsy have included anxiety disorders. In one study that addressed this issue, Bladin" found that 58 of 115 consecutive patients (50%) experienced transient anxiety postoperatively. Short-term hospitalization was used in 17
PSYCHIATRIC DISORDERS AND TREATMENT OF EPILEPSY
1203
cases (15%). Preoperatively, 44% of this sample of patients had anxiety. For unclear reasons, postoperative anxiety was significantly associated with left-sided lesions. The author suspected but could not prove that abrupt termination of long-term treatment with benzodiazepine anticonvulsants such as clonazepam was a factor. In some cases, anxiety decreases postoperatively. A published case" described the remission of obsessive-compulsive disorder after a right temporal lobectomy for refractory partial seizures. The authors speculated that this points to an organic cause for the severe anxiety disorder.
NONEPILEPTIC SEIZURES Nonepileptic seizures, also known as pseudoseizures, occasionally coexist with epileptic seizures in some patients. The medical and psychiatric differential diagnosis of nonepileptic spells is discussed in another article in this symposium." A dilemma arises when patients with nonepileptic events attributed to a psychiatric cause meet the neurologic criteria for surgical treatment of epilepsy because these patients may be at risk for persisting nonepileptic events even if free of epileptic seizures. A Mayo case series examined a small group of patients with postoperative nonepileptic seizures, some of whom also had preoperative somatoform symptoms." Patients at risk were found to have a longer duration of epilepsy, lower full-scale IQ, inadequate coping strategies, poor coping skills, and an overall tendency to somatize-findings that indicate postoperative psychosocial adjustment may be difficult. Patients with nonepileptic seizures who are otherwise appropriate candidates for surgical treatment of epilepsy should receive therapy for the nonepileptic episodes before undergoing a neurosurgical procedure. Ideally, the nonepileptic spells can be eliminated before surgical intervention. Treatment at our institution varies, depending on the patient's psychiatric diagnosis. Nonepileptic events associated with depressive or panic disorder can be managed with antidepressants or sedative-hypnotic agents; those associated with conversion disorder are managed with behavioral or cognitive therapy. Although most patients are treated on an outpatient basis, selected patients with severe or frequent spells have required inpatient treatment. Once the patient's condition has been stabilized, a surgical procedure can be reconsidered with the prospects of a better psychiatric outcome. OTHER DISORDERS Preoperatively, excessive use of caffeine may contribute to seizure refractoriness and anxiety disorders." At our institution, patients are advised to reduce their consumption of caffeine to a maximum of the equivalent of three cups of caffeinated coffee daily.
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
1204 PSYCHIATRIC DISORDERS AND TREATMENT OF EPILEPSY
The concept of the "temporal lobe epilepsy personality" has been debated for years. This label describes a group of patients with epilepsy who have hypergraphia, preoccupation with philosophical matters, and reduced interest in sexual matters." Although the debate continues, several studies have found no differences between such patients and other groups of psychiatric and neurologic patients.F-" No studies have examined this syndrome in candidates for surgical treatment of epilepsy, and at our institution, we do not screen for this constellation of symptoms. CONCLUSION No psychiatric factors are absolute contraindications to surgical treatment of epilepsy. The decision to proceed with operative intervention must be based on the patient's epilepsy history and neurologic factors. The main goals should be decreased frequency and severity of the patient's seizures. Attaining these goals, especially if the patient becomes free of seizures, will enhance the patient's possibility of improvement in other respects. Clearly, the approach of identifying and stabilizing psychiatric symptoms preoperatively is preferable. Especially with chronic psychotic disorders, reduction of the psychiatric symptoms should not be the primary objective of surgical treatment. The paucity of adverse reports in the setting of more widespread use of the operative management of epilepsy gives the impression that unsatisfactory psychiatric outcomes are rare. In the experience of our institution and others, most patients with epilepsy, with or without a history of psychiatric disorders, tolerate a surgical procedure well and report a substantially improved postoperative quality of life. 16
Mayo Clin Proc, December 1996, Vol 71
5. 6.
7.
8. 9. 10. II.
12. 13. 14. 15. 16. 17.
18. REFERENCES 1. Mendez MF, Grau R, Doss RC, Taylor JL. Schizophrenia in epilepsy: seizure and psychosis variables. Neurology 1993; 43: 10731077 2. Fenwick PBe. Postscript: what should be included in a standardized psychiatric assessment? In: Engel J Jr, editor. Surgical Treatment of the Epilepsies. New York: Raven Press, 1987: 2505-2510 3. Stagno SJ, Smith ML. The presurgical workup: evaluation of psychiatric issues and informed consent. In: Luders HO, editor. Epilepsy Surgery. New York: Raven Press, 1992: 453-459 4. Savard G. Psychosis and the surgery of epilepsy. In: Luders HO, editor. Epilepsy Surgery. New York: Raven Press, 1992: 461465
19. 20. 21. 22. 23.
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