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The importance of theory of mind in epilepsy
Epilepsy & Behavior 39 (2014) 143–144
Contents lists available at ScienceDirect
Epilepsy & Behavior journal homepage: www.elsevier.com/locate/yebeh
Editorial
The importance of theory of mind in epilepsy
Social cognition has become an established and productive field of research with demonstrated clinical applications. The prominence of this domain was boosted by the concept of theory of mind (ToM) and the methodologies developed for assessment including brain imaging paradigms. Theory of mind refers to the human tendency to attribute feelings, beliefs, attitudes, and intentions to others and to oneself. Research initially in the field of autism and latterly across a range of conditions has increased our understanding of not only the mechanisms underlying impaired social competence but also the far reaching impact that such deficits can have for individuals, families, and wider social networks. As Giovagnoli highlights in her timely review in this issue of Epilepsy & Behavior, ToM research in epilepsy has lagged behind investigations into other disorders [1]. This is surprising given the involvement of frontotemporal circuitry in social cognition and the disruption of these networks in frontal and temporal lobe epilepsies and, possibly, in certain generalized epilepsy syndromes as demonstrated by recent brain connectivity studies. Theory of mind deficits provide a potential explanation of the aberrant personal styles and interpersonal difficulties previously attributed to the epileptic personality, arguably a much less helpful construct. Less pronounced ToM deficits, however, may also be socially disabling. Psychosocial problems in epilepsy have long been recognized, and these include difficulties with employment and problems in making and maintaining friendships and more intimate stable relationships. Psychosocial difficulties have been identified as predictors of a poor quality of life. Much campaigning, and it is to be welcomed, has addressed external factors such as stigma with educational programs aiming to redress stereotyped attitudes and resulting restrictive behaviors. In so doing, however, have we overlooked or, at best, attached insufficient weight to deficits in social cognition? For some individuals with epilepsy, the problem may lie within, and social difficulties may well continue even in a world in which the stigma against epilepsy was dramatically reduced. Is impaired social cognition another comorbidity of epilepsy? While I concur with much of Giovagnoli's review, the conclusion that ToM assessments need to be included in routine neuropsychological assessments demands further reflection. Is this feasible or indeed appropriate? Neuropsychology has a unique and important role in the management of epilepsy. Neuropsychological assessments provide vital information used, for example, to set realistic educational and employment goals and to enhance surgical decision-making. Neuropsychologists already have to handle a large number of cognitive tests. Indeed, a survey of neuropsychological practice worldwide reported a mean of 52 tests routinely applied. Furthermore, assessment duration averaged at 5.6 h with a
http://dx.doi.org/10.1016/j.yebeh.2014.07.006 1525-5050/© 2014 Elsevier Inc. All rights reserved.
maximum of 12 h documented [2]. Theory of mind tests or other measures of social cognition were not among the tests listed. Bolting on ToM tests as suggested even as screening measures would significantly extend the duration of assessments. Lengthy assessments certainly have a role in research studies, but in clinical settings, I would argue that this is not the best use of neuropsychology time, a limited resource in many health-care systems notwithstanding the stress of prolonged assessments for the examinee and the disruptive influence of fatigue, test anxiety, and low motivation on test performance. Assessments encompassing the social cognitive domain do, however, have considerable clinical relevance. Neuropsychologists need to keep up with research findings and to consider the value of incorporating ToM tests into some neuropsychological assessments. This would be important when referrals indicate psychosocial difficulties or when the clinical interview elicits such problems. Professionals, people with epilepsy, and their families also need to be alerted to the existence of social cognitive deficits and their potential role in causing problems at school, at work, and with interpersonal relationships. Ideally, referrals for a neuropsychological opinion should be made when problems first emerge before their consequences become entrenched or widespread. Research evidence reviewed by Giovagnoli indicates that there exists some urgency for prompt referrals for children with epilepsy. Findings to date indicate that the critical developmental window is likely to fall from mid- to latechildhood to the early teenage years; thereafter, deficits may have already developed and become an established way of evaluating and responding in social settings. From the available evidence on the ToM network, individuals undergoing resective surgery would seem to be at particular risk of developing postoperative deficits in social cognition. Investigations of surgical cohorts reviewed by Giovagnoli have provided inconclusive findings but few studies exist and mostly these have considered the impact of temporal lobe surgery. With advances in imaging and electrophysiological techniques, there has been a steep increase in the numbers of frontal lobe surgeries undertaken and the risks for this group might well be greater. Inclusion of ToM testing into pre- and postoperative assessments has the potential to yield data of relevance to the surgical decision-making process. An acquired social cognitive deficit may have a devastating impact on the quality of life even when a person is rendered seizure-free. Social cognition and the ToM work that it encompasses have considerable potential to increase our understanding of the genesis of psychosocial difficulties in epilepsy. Already, there are pointers as to how research findings might influence our ways of working. Increased research energies as Giovagnoli argues are warranted. To maximize
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clinical utility, an emphasis of such endeavors should be an exploration of the efficacy of interventions. Are deficits in social cognition fixed as might be hypothesized if the critical period for development has passed? Work with individuals with Asperger's syndrome suggests that late acquired mentalizing skills may be fragile and logical rather than intuitive and, for some individuals, psychosocial gains may be better achieved by increasing awareness and adjusting the expectations of the social environment. Disclosures The author has no financial or conflict of interest with this paper. References [1] Giovagnoli AR. The importance of theory of mind in epilepsy. Epilepsy Behav 2014. http://dx.doi.org/10.1016/j.yebeh.2014.05.021 pii: S1525-5050(14)00195-4.
[2] Djordjevic J. A survey on assessments across epilepsy centers in different countries. In: Hemstaedter C, Hermann B, Lassonde M, Kahane P, Arzimanoglou A, editors. Neuropsychology in the care of people with epilepsy. Esther, Surrey UK: John Libbey Eurotext; 2011. p. 13–26.
Pam Thompson Department of Clinical & Experimental Epilepsy, Institute of Neurology, UCL Queen Square, London UK Epilepsy Society, Chalfont St. Peter, Buckinghamshire, UK Tel.: +44 1494 601346. E-mail address: [email protected].
7 July 2014
Contents lists available at ScienceDirect
Epilepsy & Behavior journal homepage: www.elsevier.com/locate/yebeh
Editorial
The importance of theory of mind in epilepsy
Social cognition has become an established and productive field of research with demonstrated clinical applications. The prominence of this domain was boosted by the concept of theory of mind (ToM) and the methodologies developed for assessment including brain imaging paradigms. Theory of mind refers to the human tendency to attribute feelings, beliefs, attitudes, and intentions to others and to oneself. Research initially in the field of autism and latterly across a range of conditions has increased our understanding of not only the mechanisms underlying impaired social competence but also the far reaching impact that such deficits can have for individuals, families, and wider social networks. As Giovagnoli highlights in her timely review in this issue of Epilepsy & Behavior, ToM research in epilepsy has lagged behind investigations into other disorders [1]. This is surprising given the involvement of frontotemporal circuitry in social cognition and the disruption of these networks in frontal and temporal lobe epilepsies and, possibly, in certain generalized epilepsy syndromes as demonstrated by recent brain connectivity studies. Theory of mind deficits provide a potential explanation of the aberrant personal styles and interpersonal difficulties previously attributed to the epileptic personality, arguably a much less helpful construct. Less pronounced ToM deficits, however, may also be socially disabling. Psychosocial problems in epilepsy have long been recognized, and these include difficulties with employment and problems in making and maintaining friendships and more intimate stable relationships. Psychosocial difficulties have been identified as predictors of a poor quality of life. Much campaigning, and it is to be welcomed, has addressed external factors such as stigma with educational programs aiming to redress stereotyped attitudes and resulting restrictive behaviors. In so doing, however, have we overlooked or, at best, attached insufficient weight to deficits in social cognition? For some individuals with epilepsy, the problem may lie within, and social difficulties may well continue even in a world in which the stigma against epilepsy was dramatically reduced. Is impaired social cognition another comorbidity of epilepsy? While I concur with much of Giovagnoli's review, the conclusion that ToM assessments need to be included in routine neuropsychological assessments demands further reflection. Is this feasible or indeed appropriate? Neuropsychology has a unique and important role in the management of epilepsy. Neuropsychological assessments provide vital information used, for example, to set realistic educational and employment goals and to enhance surgical decision-making. Neuropsychologists already have to handle a large number of cognitive tests. Indeed, a survey of neuropsychological practice worldwide reported a mean of 52 tests routinely applied. Furthermore, assessment duration averaged at 5.6 h with a
http://dx.doi.org/10.1016/j.yebeh.2014.07.006 1525-5050/© 2014 Elsevier Inc. All rights reserved.
maximum of 12 h documented [2]. Theory of mind tests or other measures of social cognition were not among the tests listed. Bolting on ToM tests as suggested even as screening measures would significantly extend the duration of assessments. Lengthy assessments certainly have a role in research studies, but in clinical settings, I would argue that this is not the best use of neuropsychology time, a limited resource in many health-care systems notwithstanding the stress of prolonged assessments for the examinee and the disruptive influence of fatigue, test anxiety, and low motivation on test performance. Assessments encompassing the social cognitive domain do, however, have considerable clinical relevance. Neuropsychologists need to keep up with research findings and to consider the value of incorporating ToM tests into some neuropsychological assessments. This would be important when referrals indicate psychosocial difficulties or when the clinical interview elicits such problems. Professionals, people with epilepsy, and their families also need to be alerted to the existence of social cognitive deficits and their potential role in causing problems at school, at work, and with interpersonal relationships. Ideally, referrals for a neuropsychological opinion should be made when problems first emerge before their consequences become entrenched or widespread. Research evidence reviewed by Giovagnoli indicates that there exists some urgency for prompt referrals for children with epilepsy. Findings to date indicate that the critical developmental window is likely to fall from mid- to latechildhood to the early teenage years; thereafter, deficits may have already developed and become an established way of evaluating and responding in social settings. From the available evidence on the ToM network, individuals undergoing resective surgery would seem to be at particular risk of developing postoperative deficits in social cognition. Investigations of surgical cohorts reviewed by Giovagnoli have provided inconclusive findings but few studies exist and mostly these have considered the impact of temporal lobe surgery. With advances in imaging and electrophysiological techniques, there has been a steep increase in the numbers of frontal lobe surgeries undertaken and the risks for this group might well be greater. Inclusion of ToM testing into pre- and postoperative assessments has the potential to yield data of relevance to the surgical decision-making process. An acquired social cognitive deficit may have a devastating impact on the quality of life even when a person is rendered seizure-free. Social cognition and the ToM work that it encompasses have considerable potential to increase our understanding of the genesis of psychosocial difficulties in epilepsy. Already, there are pointers as to how research findings might influence our ways of working. Increased research energies as Giovagnoli argues are warranted. To maximize
144
Editorial
clinical utility, an emphasis of such endeavors should be an exploration of the efficacy of interventions. Are deficits in social cognition fixed as might be hypothesized if the critical period for development has passed? Work with individuals with Asperger's syndrome suggests that late acquired mentalizing skills may be fragile and logical rather than intuitive and, for some individuals, psychosocial gains may be better achieved by increasing awareness and adjusting the expectations of the social environment. Disclosures The author has no financial or conflict of interest with this paper. References [1] Giovagnoli AR. The importance of theory of mind in epilepsy. Epilepsy Behav 2014. http://dx.doi.org/10.1016/j.yebeh.2014.05.021 pii: S1525-5050(14)00195-4.
[2] Djordjevic J. A survey on assessments across epilepsy centers in different countries. In: Hemstaedter C, Hermann B, Lassonde M, Kahane P, Arzimanoglou A, editors. Neuropsychology in the care of people with epilepsy. Esther, Surrey UK: John Libbey Eurotext; 2011. p. 13–26.
Pam Thompson Department of Clinical & Experimental Epilepsy, Institute of Neurology, UCL Queen Square, London UK Epilepsy Society, Chalfont St. Peter, Buckinghamshire, UK Tel.: +44 1494 601346. E-mail address: [email protected].
7 July 2014