CLINICAL
AND
RESEARCH
REPORTS
Interictal Psychiatric in Treatment-Refractory
Morbidity and Focus of Epilepsy Patients Admitted to an Epilepsy Unit
Rahul Manchanda, M.B.B.S., Richard S. McLachlan, M.D.,
Of 71 consecutive classified f
as having
erences
and
patients
were
M.D., M.R.C.Psych., F.R.C.P.(C), Betsy Schaefer, B.A., F.R.C.P.(C), and Warren T. Blume, M.D., F.R.C.P.(C)
admitted
psychiatric
evident
to an epilepsy
disorders
to support
by using
a specific
J
Psychiatry
1992;
the
hospital,
Health
between
the
32 (45%)
Questionnaire. type
or focus
were No
dif-
of epilepsy
149:1096-1098)
everal studies attest to higher rates of psychiatric morbidity in epileptic patients ( 1-4). Furthermore, a particularly strong association between temporal lobe epilepsy and psychiatric disorders has been supported by some investigators (1-3, 5, 6) but not by others (710). A general practice survey (4) showed a difference in the frequency of psychiatric disturbance between focal and primary generalized epilepsy but not between temporal and focal nontemporal lobe epilepsy. Thus, the controversy regarding psychiatric illness in patients with temporal lobe epilepsy continues. study
general
General
relationship
S
This
the
ofa
psychopathology.
(Am
whether in patients
unit
was
carried
prevalence
out
and
primarily
degree
to
determine
of psychopathology
seizures with an average frequency of at least once every month even with polytherapy using up to three different anticonvulsants for a period of at least 2 years. The seizure disorder was categorized according to the classification of the International League Against Epilepsy (11). All patients had standard EEG telemetry using scalp electrodes with continuous monitoring until sufficient seizures were recorded to delineate the focus. When scalp recordings failed to do this, telemetry was continued with implanted subdural dcctrodes. In addition to this standard investigation, all patients
were
asked
to fill in the self-administered
60-item
Gen-
psychiatric assessment as part of the investigation for epilepsy surgery. Another aim was to determine whether patients with a temporal lobe focus of seizures have a higher prevalence of psychopathology. Furthermore, the possibility of a relationship between laterality of seizure focus and psychiatric disturbance was investigated.
eral Health Questionnaire (12). A score of 12 or higher on this questionnaire identifies respondents with a nonpsychotic psychiatric illness. The reliability and validity of the questionnaire has been extensively studied (12, 13), and the questionnaire is widely accepted as a screening instrument for defining psychiatric illness in medically ill populations.
METHOD
RESULTS
The sample for this study consisted of all consecutive adult (age 116 and older) patients with epilepsy admitted to an epilepsy unit of a general hospital during a 20-month period. All patients were refractory to mcdical treatment and were admitted for assessment for neurosurgical intervention. Patients were considered treatment refractory if they continued to experience
Seventy-one were included
with
intractable
epilepsy
warranted
routine
Received July 9, 1991; revision received Dec. 10, 1991; accepted Jan. 10, 1992. From the Department of Psychiatry and the Department of Clinical Neurological Sciences, University Hospital. Address reprint requests to Dr. Manchanda, University Hospital, Box 5339, 339 Windermere Rd., London, Ontario, Canada N6A SAS. Copyright 0 1992 American Psychiatric Association.
1096
patients admitted to the epilepsy unit in the sample. Thirty-six (51%) of the patients were men, and 35 (49%) were women. Their mean age was 29 years (SD=10.14). Forty-four (62%) were single, and 23 (32%) were married; four patients were separated or widowed. Their mean age at onset of epilepsy was 12.2 years (SD=9.4), the mean duration of their epilepsy was 16.8 years (SD=8.62), and their mean number of seizures per week was 9.6 (SD=17.8). Thirty-five (49%) ofthe patients had simple or complex partial seizures, 28 (39%) had simple or complex partial seizures with secondary generalization, and eight (111%) had primary generalized seizures. The primary seizure focus was categorized as temporal in 47 (66%)
Am
J
Psychiatry
1 49:8,
August
1992
CLINICAL
of the patients, nontemporal in 17 (24%), and indeterminate in seven (10%). Differences among these groups on demographic variables were examined by using a chi-square test for categorical variables; no significant differences were found. Of the 47 patients who had temporal lobe epilepsy, 19 (40%) had a left-sided focus, 20 (43%) had a right-sided focus, and eight (17%) were bitemporat. According to their responses on the 60-item General Health Questionnaire, 32 (45%) ofthe 71 patients were categorized as having psychiatric disorders (their scores were 12 or higher). When having a General Health Q uestionnaire score of 12 or higher was compared with the seizure focus by using a chi-square test for comparison of means (table 1), no significant differences were observed (x2=O.7S df=2, p=O.69). When General Health Questionnaire scores and lateratity of
seizure focus were compared, no significant differences were observed; 10 (48%) of the 21 patients with a temporal focus who were identified as having psychiatric disorders had a left temporal focus, and five (56%) of the nine patients with a nontemporal focus who were identified as having psychiatric disorders had a right nontemporal focus.
DISCUSSION
The highest frequency of psychiatric morbidity in epileptic patients is seen among institutionalized patients and those attending clinics specializing in the treatment of intractable seizure disorders (14). Using the General Health Questionnaire, we identified 32 (45%) ofour 71 patients as having psychiatric disorders. These findings are consistent with those of Edeh and Toone (4), whose case material was unselected and community based. However, our results are probably an underestimate given that the sample consisted of a group of patients with more severe, treatment-refractory epilepsy. One or more of the following factors may account for this. Uncooperative, disturbed patients and those with serious psychiatric problems were less likely to be admitted to this inpatient epilepsy unit, where testing procedures mequire considerable cooperation and patience from the subjects. Furthermore, the General Health Questionnaire is a measure of nonpsychotic emotional illness and does not detect personality disorders. Gibbs’s findings that psychiatric disorders are three times
more
common
among
cal epilepsy than among focal epilepsy (5) remains also fails to support such no differences based on which have been reported 16). However, studies tween laterality of seizure looked at specific aspects
patients
with
study. It may be argued that the General Health naire measured anxiety related to admission not
Am]
assessed
Psychiatry
temporal
fo-
patients with extratemporal controversial (4). This study a claim. In addition, we found laterality of the seizure focus, by some investigators (15, supporting relationships befocus and psychopathology of psychopathology that were
in this
149:8,
August
1992
Questionfor possi-
AND
RESEARCH
REPORTS
TABLE 1. General Health Question naire Scores and Seizure Focus of 70 Patients With EpiIeps Temporal Focus (N=47)
Indeterminate Focus
Nontemporal Focus (N=17)
General Health Questionnaire Score
N
%
N
%
N
%
liandlower 12 and higher
26 21
55.3 44.7
8
47.1
9
52.9
4 2
66.7 33.3
aData
were missing
for one patient
with
(N=7)
indeterminate
focus.
ble neurosurgical treatment. The data do not support this. First, examination of the mean scones on subscales of the General Health Questionnaire shows that atthough the mean anxiety score was the highest in the total sample, the patients with a General Health Questionnaire score of 12 or higher scored highest on the somatic subscale. Second, our preliminary analysis of the General Health Questionnaire scores of a similar group of patients assessed during hospitalization and 1 year later as outpatients (these patients did not have neurosurgery) did not reveal a significant reduction in General Health Questionnaire scores. Third, even when the cutoff score was increased to 16, no significant findings emerged between localization of seizure focus and having a psychiatric disorder according to the General Health Questionnaire. There are limitations to the conclusions that can be drawn from this study, however. The sample studied was selected and not representative of a general epilepsy population. The patients were treatment refractory and were admitted to a specialized unit for possible neurosurgical intervention. However, this study has the advantage of a large number of consecutive patients with a welt-defined seizure focus. In the past, an apparent excess of temporal lobe epilepsy has been reported in psychiatrically abnormal patients with epilepsy. This study provides an opportunity to examine psychiatric morbidity in a large number of patients with focal epilepsy, both temporal and nontemporal. Another limitation of this study is that the patients were not clinically evaluated but were assessed by using the General Health Questionnaire. This is because the study was essentially a pilot project to determine whether detailed psychiatric assessments are warranted in every candidate for epilepsy surgery (17). The General Health Questionnaire is essentially a screening test, but
it
k,es
represent
a general
measure
of nonpsychotic
psychopathology in a medically ill population. Therefore, a conclusion that 45 % of patients have psychiatric morbidity would at best be an approximation. However, it is also an indication for us to carry out detailed preoperative assessments on this group of patients. Alt patients currently admitted to the epilepsy unit undergo a psychiatric diagnostic interview and stand-
ardized
rating
such data can and adjustments. be forthcoming
scale predict The in the
assessments
to determine
postoperative emotional data from these evaluations near future.
whether status will
1097
CLINICAL
AND
RESEARCH
REPORTS
REFERENCES 1. Pond
DA, Bidwell BH: A survey of epilepsy in fourteen II: social and psychological aspects. Epilepsia 1:285-299
practices,
general I 959;
2. Gudmundsson G: Epilepsy in Iceland: a clinical and epidemiological investigation. Acta Neurol Scand Suppl 1966; 25:1-124 3. Zielinski JJ: Epilepsy mortality rate and cause of death. Epilepsia 1974; 15:191-201 4. Edeh J, Toone B: Relationship between interictal psychopathology and the type of epilepsy. Br J Psychiatry 1987; 15 1:95-101 S. Gibbs FA: Ictal and non-ictal psychiatric disorders in temporal lobe epilepsy. J Nerv Ment Dis I 951; 11:522-528 6. Currie 5, Heathfield KWG, Henson RA, Scott DF: Clinical course and prognosis of temporal lobe epilepsy: a survey of 666 patients. Brain 1 971; 94:173-190 7.
Small
JG,
Milstein
V, Stevens
JR:
Are
psychomotor
epileptics
dif-
ferent? a controlled study. Arch Neurol 1962; 7:187-194 8. Stevens JR: Psychiatric implications of psychomotor epilepsy. Arch Gen Psychiatry 1966; 14:461-471 9. Standage KF, Fenton GW: Psychiatric symptom profiles of pa-
1098
tients with epilepsy: a controlled investigation. Psychol Med 1975; 5:152-1 60 10. Kaminer Y, Apter A, Aviv P, Lerman P, Tyano 5: Psychopathology and temporal lobe epilepsy in adolescents. Acta Neurol Scand 1988; 77:640-644 1 1 . Commission on Classification and Terminology of the International League Against Epilepsy: Proposal for revised clinical and electro-encephalographic classification of epileptic seizures. Epilepsy 1981; 22:489-501 12. Goldberg DP: Manual of the General Health Questionnaire. Slough, NFER-Nelson, 1972 13. Goldberg DP, Williams P: The User’s Guide to the General Health Questionnaire. Slough, NFER-Nelson, I 988 14. Stevens JR: Psychiatric aspects of epilepsy. J Clin Psychiatry 1988; 49(4, section 2):49-57 is. Flor-Henry P: Psychosis and temporal lobe epilepsy: a controlled investigation. Epilepsia 1969; 10:363-395 16. Bear DM, Fedio P: Quantitative analysis of interictal behavior in temporal lobe epilepsy. Arch Neurol 1977; 34:454-467 I 7. Fenwick P: Psychiatric assessment and temporal lobectomy. Acta Neurol Scand Suppl 1988; 78:96-102
AmJ
Psychiatry
149:8,
August
1992
AND
RESEARCH
REPORTS
Interictal Psychiatric in Treatment-Refractory
Morbidity and Focus of Epilepsy Patients Admitted to an Epilepsy Unit
Rahul Manchanda, M.B.B.S., Richard S. McLachlan, M.D.,
Of 71 consecutive classified f
as having
erences
and
patients
were
M.D., M.R.C.Psych., F.R.C.P.(C), Betsy Schaefer, B.A., F.R.C.P.(C), and Warren T. Blume, M.D., F.R.C.P.(C)
admitted
psychiatric
evident
to an epilepsy
disorders
to support
by using
a specific
J
Psychiatry
1992;
the
hospital,
Health
between
the
32 (45%)
Questionnaire. type
or focus
were No
dif-
of epilepsy
149:1096-1098)
everal studies attest to higher rates of psychiatric morbidity in epileptic patients ( 1-4). Furthermore, a particularly strong association between temporal lobe epilepsy and psychiatric disorders has been supported by some investigators (1-3, 5, 6) but not by others (710). A general practice survey (4) showed a difference in the frequency of psychiatric disturbance between focal and primary generalized epilepsy but not between temporal and focal nontemporal lobe epilepsy. Thus, the controversy regarding psychiatric illness in patients with temporal lobe epilepsy continues. study
general
General
relationship
S
This
the
ofa
psychopathology.
(Am
whether in patients
unit
was
carried
prevalence
out
and
primarily
degree
to
determine
of psychopathology
seizures with an average frequency of at least once every month even with polytherapy using up to three different anticonvulsants for a period of at least 2 years. The seizure disorder was categorized according to the classification of the International League Against Epilepsy (11). All patients had standard EEG telemetry using scalp electrodes with continuous monitoring until sufficient seizures were recorded to delineate the focus. When scalp recordings failed to do this, telemetry was continued with implanted subdural dcctrodes. In addition to this standard investigation, all patients
were
asked
to fill in the self-administered
60-item
Gen-
psychiatric assessment as part of the investigation for epilepsy surgery. Another aim was to determine whether patients with a temporal lobe focus of seizures have a higher prevalence of psychopathology. Furthermore, the possibility of a relationship between laterality of seizure focus and psychiatric disturbance was investigated.
eral Health Questionnaire (12). A score of 12 or higher on this questionnaire identifies respondents with a nonpsychotic psychiatric illness. The reliability and validity of the questionnaire has been extensively studied (12, 13), and the questionnaire is widely accepted as a screening instrument for defining psychiatric illness in medically ill populations.
METHOD
RESULTS
The sample for this study consisted of all consecutive adult (age 116 and older) patients with epilepsy admitted to an epilepsy unit of a general hospital during a 20-month period. All patients were refractory to mcdical treatment and were admitted for assessment for neurosurgical intervention. Patients were considered treatment refractory if they continued to experience
Seventy-one were included
with
intractable
epilepsy
warranted
routine
Received July 9, 1991; revision received Dec. 10, 1991; accepted Jan. 10, 1992. From the Department of Psychiatry and the Department of Clinical Neurological Sciences, University Hospital. Address reprint requests to Dr. Manchanda, University Hospital, Box 5339, 339 Windermere Rd., London, Ontario, Canada N6A SAS. Copyright 0 1992 American Psychiatric Association.
1096
patients admitted to the epilepsy unit in the sample. Thirty-six (51%) of the patients were men, and 35 (49%) were women. Their mean age was 29 years (SD=10.14). Forty-four (62%) were single, and 23 (32%) were married; four patients were separated or widowed. Their mean age at onset of epilepsy was 12.2 years (SD=9.4), the mean duration of their epilepsy was 16.8 years (SD=8.62), and their mean number of seizures per week was 9.6 (SD=17.8). Thirty-five (49%) ofthe patients had simple or complex partial seizures, 28 (39%) had simple or complex partial seizures with secondary generalization, and eight (111%) had primary generalized seizures. The primary seizure focus was categorized as temporal in 47 (66%)
Am
J
Psychiatry
1 49:8,
August
1992
CLINICAL
of the patients, nontemporal in 17 (24%), and indeterminate in seven (10%). Differences among these groups on demographic variables were examined by using a chi-square test for categorical variables; no significant differences were found. Of the 47 patients who had temporal lobe epilepsy, 19 (40%) had a left-sided focus, 20 (43%) had a right-sided focus, and eight (17%) were bitemporat. According to their responses on the 60-item General Health Questionnaire, 32 (45%) ofthe 71 patients were categorized as having psychiatric disorders (their scores were 12 or higher). When having a General Health Q uestionnaire score of 12 or higher was compared with the seizure focus by using a chi-square test for comparison of means (table 1), no significant differences were observed (x2=O.7S df=2, p=O.69). When General Health Questionnaire scores and lateratity of
seizure focus were compared, no significant differences were observed; 10 (48%) of the 21 patients with a temporal focus who were identified as having psychiatric disorders had a left temporal focus, and five (56%) of the nine patients with a nontemporal focus who were identified as having psychiatric disorders had a right nontemporal focus.
DISCUSSION
The highest frequency of psychiatric morbidity in epileptic patients is seen among institutionalized patients and those attending clinics specializing in the treatment of intractable seizure disorders (14). Using the General Health Questionnaire, we identified 32 (45%) ofour 71 patients as having psychiatric disorders. These findings are consistent with those of Edeh and Toone (4), whose case material was unselected and community based. However, our results are probably an underestimate given that the sample consisted of a group of patients with more severe, treatment-refractory epilepsy. One or more of the following factors may account for this. Uncooperative, disturbed patients and those with serious psychiatric problems were less likely to be admitted to this inpatient epilepsy unit, where testing procedures mequire considerable cooperation and patience from the subjects. Furthermore, the General Health Questionnaire is a measure of nonpsychotic emotional illness and does not detect personality disorders. Gibbs’s findings that psychiatric disorders are three times
more
common
among
cal epilepsy than among focal epilepsy (5) remains also fails to support such no differences based on which have been reported 16). However, studies tween laterality of seizure looked at specific aspects
patients
with
study. It may be argued that the General Health naire measured anxiety related to admission not
Am]
assessed
Psychiatry
temporal
fo-
patients with extratemporal controversial (4). This study a claim. In addition, we found laterality of the seizure focus, by some investigators (15, supporting relationships befocus and psychopathology of psychopathology that were
in this
149:8,
August
1992
Questionfor possi-
AND
RESEARCH
REPORTS
TABLE 1. General Health Question naire Scores and Seizure Focus of 70 Patients With EpiIeps Temporal Focus (N=47)
Indeterminate Focus
Nontemporal Focus (N=17)
General Health Questionnaire Score
N
%
N
%
N
%
liandlower 12 and higher
26 21
55.3 44.7
8
47.1
9
52.9
4 2
66.7 33.3
aData
were missing
for one patient
with
(N=7)
indeterminate
focus.
ble neurosurgical treatment. The data do not support this. First, examination of the mean scones on subscales of the General Health Questionnaire shows that atthough the mean anxiety score was the highest in the total sample, the patients with a General Health Questionnaire score of 12 or higher scored highest on the somatic subscale. Second, our preliminary analysis of the General Health Questionnaire scores of a similar group of patients assessed during hospitalization and 1 year later as outpatients (these patients did not have neurosurgery) did not reveal a significant reduction in General Health Questionnaire scores. Third, even when the cutoff score was increased to 16, no significant findings emerged between localization of seizure focus and having a psychiatric disorder according to the General Health Questionnaire. There are limitations to the conclusions that can be drawn from this study, however. The sample studied was selected and not representative of a general epilepsy population. The patients were treatment refractory and were admitted to a specialized unit for possible neurosurgical intervention. However, this study has the advantage of a large number of consecutive patients with a welt-defined seizure focus. In the past, an apparent excess of temporal lobe epilepsy has been reported in psychiatrically abnormal patients with epilepsy. This study provides an opportunity to examine psychiatric morbidity in a large number of patients with focal epilepsy, both temporal and nontemporal. Another limitation of this study is that the patients were not clinically evaluated but were assessed by using the General Health Questionnaire. This is because the study was essentially a pilot project to determine whether detailed psychiatric assessments are warranted in every candidate for epilepsy surgery (17). The General Health Questionnaire is essentially a screening test, but
it
k,es
represent
a general
measure
of nonpsychotic
psychopathology in a medically ill population. Therefore, a conclusion that 45 % of patients have psychiatric morbidity would at best be an approximation. However, it is also an indication for us to carry out detailed preoperative assessments on this group of patients. Alt patients currently admitted to the epilepsy unit undergo a psychiatric diagnostic interview and stand-
ardized
rating
such data can and adjustments. be forthcoming
scale predict The in the
assessments
to determine
postoperative emotional data from these evaluations near future.
whether status will
1097
CLINICAL
AND
RESEARCH
REPORTS
REFERENCES 1. Pond
DA, Bidwell BH: A survey of epilepsy in fourteen II: social and psychological aspects. Epilepsia 1:285-299
practices,
general I 959;
2. Gudmundsson G: Epilepsy in Iceland: a clinical and epidemiological investigation. Acta Neurol Scand Suppl 1966; 25:1-124 3. Zielinski JJ: Epilepsy mortality rate and cause of death. Epilepsia 1974; 15:191-201 4. Edeh J, Toone B: Relationship between interictal psychopathology and the type of epilepsy. Br J Psychiatry 1987; 15 1:95-101 S. Gibbs FA: Ictal and non-ictal psychiatric disorders in temporal lobe epilepsy. J Nerv Ment Dis I 951; 11:522-528 6. Currie 5, Heathfield KWG, Henson RA, Scott DF: Clinical course and prognosis of temporal lobe epilepsy: a survey of 666 patients. Brain 1 971; 94:173-190 7.
Small
JG,
Milstein
V, Stevens
JR:
Are
psychomotor
epileptics
dif-
ferent? a controlled study. Arch Neurol 1962; 7:187-194 8. Stevens JR: Psychiatric implications of psychomotor epilepsy. Arch Gen Psychiatry 1966; 14:461-471 9. Standage KF, Fenton GW: Psychiatric symptom profiles of pa-
1098
tients with epilepsy: a controlled investigation. Psychol Med 1975; 5:152-1 60 10. Kaminer Y, Apter A, Aviv P, Lerman P, Tyano 5: Psychopathology and temporal lobe epilepsy in adolescents. Acta Neurol Scand 1988; 77:640-644 1 1 . Commission on Classification and Terminology of the International League Against Epilepsy: Proposal for revised clinical and electro-encephalographic classification of epileptic seizures. Epilepsy 1981; 22:489-501 12. Goldberg DP: Manual of the General Health Questionnaire. Slough, NFER-Nelson, 1972 13. Goldberg DP, Williams P: The User’s Guide to the General Health Questionnaire. Slough, NFER-Nelson, I 988 14. Stevens JR: Psychiatric aspects of epilepsy. J Clin Psychiatry 1988; 49(4, section 2):49-57 is. Flor-Henry P: Psychosis and temporal lobe epilepsy: a controlled investigation. Epilepsia 1969; 10:363-395 16. Bear DM, Fedio P: Quantitative analysis of interictal behavior in temporal lobe epilepsy. Arch Neurol 1977; 34:454-467 I 7. Fenwick P: Psychiatric assessment and temporal lobectomy. Acta Neurol Scand Suppl 1988; 78:96-102
AmJ
Psychiatry
149:8,
August
1992
