The Neurobehavioral Treatment of Epilepsy
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The cognitive, neurobehavioral, social, and psychiatric comorbidities add to the burden of this common disease. This burden remains, and at times increases, over the lifespan of the individual with epilepsy. Psychiatric and neurobehavioral comorbidities of epilepsy have been well reported in both the psychiatric and neurology literature. This is akin to the chicken and egg causality dilemma. Did the seizure disorder come first followed by the psychiatric and behavioral morbidities or are patients with psychiatric and behavioral disorders more prone to seizure disorders?
Whatever the answer to the above question, there is a pressing need to better identify these comorbidities in our patients with epilepsy and to develop epilepsy-specific and individual specific treatment options.
Epilepsy & Behavior
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Researcher Academy Author Services Try out personalized alert features. Read more. Sriram Ramgopal Sigride Thome-Souza Eugen Trinka Markus Leitinger. Nuria Lacuey Vasant Garg Max Catchpool Kim Dalziel Cannabinoids in treatment-resistant epilepsy: A review Brooke K. O'Connell David Gloss William Diprose Frederick Sundram Evan C. Rosenberg Pabitra H. Poul Jennum Rikke Ibsen Olga Braams Caragh Maher Alice Mead. Whitney Fitts Nana Tassiou Rahamatou No effective therapies are established for other cognitive problems, but pragmatic, compensatory strategies can be helpful. Behavioral disorders include fatigue, depression, anxiety, and psychosis.
Many of these disorders usually respond well to pharmacotherapy, which can be supplemented by psychotherapy. Cognitive and behavioral disorders can be the greatest cause of morbidity and impaired quality of life, often overshadowing seizures. Yet these problems often go unrecognized and, even when identified, are often undertreated or untreated. Therapy for cognitive and behavioral disorders in patients with epilepsy remains unsatisfactory.
Encompassing neurology, psychiatry, and psychology, neurobehavioral therapies usually treat symptoms, not the disease process. In caring for patients with epilepsy, we often confuse seizure control with treatment of the underlying process.
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However, we are very far from this goal, which could normalize the seizure threshold and improve cognition and behavior. Therapy for cognitive and neurobehavioral symptoms is similar across neurologic disorders. Anxiety, depression, aggression, and psychosis appear to respond to the same pharmacotherapies regardless of whether the patient has epilepsy, stroke, or multiple sclerosis. Clinical features, such as the patient's age, comorbid disorders e.
Neurobehavioral disorders often remain undiagnosed. A patient may offer a complaint that is dismissed, and even when the complaint is noted, its significance may remain unappreciated.
Neurobehavioral and Psychiatric Comorbidities of Epilepsy
A problem noted by a nurse or a diagnosis buried at the end of a neuropsychological report is often not followed. Effective therapy depends on the correct diagnosis. Cognitive and behavioral disorders are diagnosed by identifying symptoms, classifying the syndrome, discovering the etiology, and localizing the brain area of dysfunction, without losing sight of the person behind the disorder.
Effective therapies may require sensitive communication and exploration of the person and his or her world. Problems with compliance are often discovered by this approach. Although psychopharmacotherapy is often underutilized in epilepsy patients, caring should not stop there. For example, in addition to prescribing a selective serotonin reuptake inhibitor SSRI for a depressed patient, emotional stressors should be explored and other factors considered e.
Omissions and misconceptions limit the diagnosis and treatment of behavioral disorders.
A central element of behavioral medicine is simply asking a patient how he or she really feels. Look the patient in the eye as he or she speaks; assess eye contact, comfort, hesitation, directness, and body language, and the ease of the patient's own answer. One must listen to a patient's story, but listen hard, beyond the superficial layer, and try to feel what the patient is feeling. Many psychological and neurologic disorders cause the patient to neglect or deny his or her feelings and problems. Family members, friends, and caregivers must also be interviewed. Therapy for neurobehavioral disorders in epilepsy favors a biological approach.
Therapy for neurobehavioral disorders in epilepsy.
Behavioral, humanistic, and practical approaches are relatively neglected. Stress aggravates most neurologic and neurobehavioral disorders, including epilepsy and the commonly associated depression, anxiety, and psychotic disorders. Physicians often underestimate the impact of patients' stressors, environment, family, and fears.
Therapeutic opportunities are thereby missed. Diagnosis and therapy must be balanced, with emphasis on the patient and his mental world, as well as his neurobiology. Patients with epilepsy often suffer from cognitive and behavioral disorders that range from subtle to lethal. Behavioral changes occur during and immediately after most seizures.
In some cases, cognition and behavior also change for prolonged periods after individual seizures or throughout the long interictal gaps. Aggressive control of seizures, and possibly reduction of interictal epileptiform activity and epileptogenesis, may help prevent interictal cognitive and behavioral disorders. Our best therapy for cognitive and behavioral disorders may be prevention, but there is little systematic study of the phenomenon either retrospectively or prospectively. Is it coincidence that impaired anterograde memory is a common interictal cognitive disorder?
Do postictal symptoms predict future interictal symptoms?
Postictal psychosis may evolve into interictal psychosis 2. Personal observation also suggests that in some patients without prior psychiatric history, periods of postictal depression develop and are followed years later by severe interictal depression. Can treatment of seizures and postictal symptoms provide an opportunity for prevention? This may be true, but the available evidence does not clearly support this view. Few studies have controlled for seizure frequency and severity, medication burden, family history, and other relevant factors.
Patients with all forms of epilepsy—including benign rolandic, childhood absence, juvenile myoclonic, and frontal lobe epilepsies—have increased rates of cognitive and behavioral problems 3 - 5.
Interictal cognitive and behavioral disorders profoundly impair the quality of life. These problems are continuous, unlike the seizures, which are intermittent. Encompassing a wide spectrum, these disorders often fit awkwardly into neuropsychiatric categories.
Even when patients fit into Diagnostic and Statistical Manual of Mental Disorders 6 categories, they often remain untreated because physicians fear using medications that might lower the seizure threshold. For example, the ability to read social cues and respond appropriately in social settings is essential for successful social function. These skills are often deficient in patients with right hemisphere or frontal lobe seizure foci. We need to develop systematic approaches to define these disorders and to develop therapeutic interventions to reduce symptom severity.
Romberg 7 recognized that memory impairment was the most common interictal disorder.
Epilepsy & Behavior - Journal - Elsevier
Patients complain of impaired recall for recently learned information, especially details and names. Left temporal seizure foci impair mainly verbal memory, and right temporal foci impair recently acquired visual, spatial, and geographic memory. As in other cognitive disorders, several factors contribute to interictal amnesia, including structural lesions 9 , neuronal dysfunction or loss, interictal epileptiform discharges 10 , recurrent seizures, and AEDs 11 - Interictal hypometabolism marks hypofunction, correlating with impaired memory when it involves the medial temporal memory structures How do we treat interictal memory disorders?