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Psychiatric Disorders in Candidatesfor Surgery for Epilepsy

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Psychiatric Disorders in Candidatesfor Surgery for Epilepsy 8287ournal of Neurology, Neurosurgery, anid Psychiatry 1996;61:82-89 Psychiatric disorders in candidates for surgery for epilepsy Rahul Manchanda, Betsy Schaefer, Richard S McLachlan, Warren T Blume, Samuel Wiebe, John P Girvin, Andrew Parrent, Paul A Derry Abstract been performed on patients with temporal Objective-To provide a descriptive lobe epilepsy. analysis of the prevalence and pattern of The standard of psychiatric assessment in psychiatric morbidity among 300 consec- the units carrying out surgery for epilepsy utive epileptic patients refractive to treat- varies widely. At the first Palm Desert work- ment and admitted during a six year shop of centres carrying out surgery for period for evaluation of their candidature epilepsy, it was concluded that psychiatric for surgery. investigation of patients in epilepsy surgery Methods-Patients underwent detailed programmes left much to be desired.' At the observation of their seizure and standard- most recent Palm Desert workshop, there was ised psychiatric assessment. Patients general consensus that each patient should were considered to be refractory to treat- have a social and psychiatric care programme ment if they continued to manifest with set goals determined before surgery and seizures with an average frequency of at the patient's progress and relationship to this least once every month even with poly- plan should be evaluated after surgery.' therapy using up to three different anti- Psychiatric problems after temporal lobec- convulsants for a period of at least two tomy have been reported in many series.4 2 years. Of the 300 patients, 231 had a tem- Considerable attention has also been focused poral lobe focus, 43 had a non-temporal on specific disorders such as interictal schizo- lobe focus, and 26 patients had a gener- phrenia-like psychosis' '3 and depression.1 22 alised and multifocal seizure onset. However, studies describing the pattern of Results and conclusions-With the DSM- psychiatric disorders among consecutive III-R criteria 142 (47-3%) patients patients undergoing assessments in an emerged as psychiatric cases. A principal epilepsy investigations unit or those assessed axis I diagnosis was made in 88 (29-3%), presurgically are lacking.'"' Even though and an axis II diagnosis (personality dis- Bladin' reports that extensive preoperative order) in another 54 (18.0%) patients. The psychiatric data, including DSM-III diagnosis most common axis I diagnosis was anxi- were available in his series of 115 temporal ety disorders (10.7%). A schizophrenia- lobectomy patients, no such information is like psychosis was seen in 13 (4-3%). Most presented. patients with personality disorders The epilepsy unit at University Hospital, showed dependent and avoidant personal- London, Canada was formally opened in May, ity traits. There was a significantly higher 1986 to investigate and treat patients with psychotic subscore on the present state medically refractory seizure disorder and par- examination in the temporal than with ticularly to determine if resective surgery or of corpus callosatomy would help. We first car- Department of the non-temporal group patients. Psychiatry These findings were not significant when ried out a pilot study23 to examine the preva- R Manchanda compared with patients with a gener- lence of psychopathology in 71 consecutive B Schaefer alised and multifocal seizure disorder. patients with intractable epilepsy to determine Department of Clinical There were no significant findings if routine psychiatric assessments were war- Neurological Sciences health R S McLachlan between the different seizure focus groups ranted. Using the general questionnaire W T Blume on the neurotic subscores. The findings (GHQ), a self rated 60 item measure of psy- S Wiebe with regard to laterality of seizure focus chopathology,24 450,4 of patients were identi- J P Girvin as cases. in our opinion, A Parrent and the neurotic or psychotic subscores fied psychiatric This, not was a psychiatric morbidity high enough to Department of were significant. Psychology, University warrant the development of a comprehensive of Western Ontario, (J Neurol Ncurosurg Psy,chiatry 1996;61:82-89) psychiatric consultation liaison service for the University Hospital, epilepsy unit. In addition to providing a clinical London, Ontario, service, detailed research evaluation of the Canada Keywords: psychiatric disorders; surgery for epilepsy P A Derry range of psychopathology in this sample is car- Correspondence to: ried out. Dr R Manchanda, This report provides a descriptive analysis Department of Psychiatry, Surgical treatment for patients with refractory University of Western epilepsy has become common since the pio- of the prevalence and pattern of psychiatric Ontario, 339 Windermere morbidity among 300 consecutive patients Road, London, Ontario neering work of Horsley.' Resection of the N6A 5A5, Canada. seizure focus or corpus callosotomy to prevent admitted to the epilepsy investigation unit for Received 29 November interhemispheric spread of the seizure activity evaluation of their surgical candidature. To and in revised form the best of our knowledge, this is the largest 29 February 1996 are the most common procedures. The largest Accepted 4 March 1996 number of epilepsy surgery operations have series of its kind. Psychiatric disorders in candidates for surgery for epilepsy883 Method chiatric interview, which included a history of The sample for this study was drawn from present and past complaints, personal, social, consecutive adult (16 and over) patients and family history, and mental state examina- refractory to treatment for epilepsy admitted tion. This was carried out to arrive at a diag- to the epilepsy unit during a six year period nosis based on the DSM-III-R criteria.' (1989-94). Patients are considered to be Information obtained from the structured clin- refractory to treatment if they continue to ical interview, present state examination28 (see manifest seizures with an average frequency of below) was also used to assist in the diagnostic at least once every month, even with polyther- process. The DSM-III-R provides descriptions apy using up to three different anticonvulsants of diagnostic categories of various mental dis- for a period of at least two years. All patients orders. A multi-axial evaluation permits each have, therefore, been in treatment and investi- case to be assessed on several "axes", each of gated extensively before being sent to the which refers to a different class of information. epilepsy unit for assessment of their surgical There are five axes in the DSM-III-R multiax- candidature.25 All patients underwent clinical ial classification. The first three axes constitute observation of the seizure phenomena. The the official diagnostic assessment. Use of the type of seizure activity was categorised by an DSM-III-R multiaxial system ensures that epileptologist (WTB; RSM; SW) according to attention is given to certain types of disorders, the classification of the International League aspects of the environment, and areas of func- Against Epilepsy.2' All patients had standard tioning that might be overlooked if the focus EEG telemetry with scalp electrodes with con- were on assessing a single presenting problem. tinuous monitoring until sufficient seizures Axis I refers to the clinical syndromes and axis were recorded to delineate the focus. When II refers to the personality disorders. The sepa- scalp recordings failed to do this, then teleme- ration between axis I and axis II ensures that try was continued with implanted subdural in the evaluation of adults, consideration is electrodes. This provided the epileptologist given to the possible presence of personality with as much certainty as possible of the type disorders that may be overlooked when atten- of epilepsy and of the seizure focus. In addi- tion is directed to the usually more florid axis I tion, all patients had a detailed clinical assess- disorder. In many instances, there is a disorder ment by a psychiatrist (RM), who was not on both axes. When a person receives more aware of the exact seizure focus in these than one diagnosis, the principal diagnosis is patients at the time of assessment. All patients the condition that was the main focus of atten- were informed of the purpose of assessment tion or treatment at the time of evaluation. and the research component to data collec- Axis III permits the clinician to indicate any tion. The project was approved by the ethics current physical disorder or condition that is committee of the University of Western potentially relevant to the understanding or Ontario. A written consent for participation management of the case. All patients in this was also obtained. The method used for evalu- study had an axis III diagnosis of epilepsy. ation was as follows: PRESENT STATE EXAMINATION"" SOCIODEMOGRAPHIC AND CLINICAL VARIABLES The present state examination (PSE) consists The group comprised 300 consecutive of a structured clinical interview for ascertain- patients admitted to the epilepsy investigation ing the presence of various psychiatric symp- unit at University Hospital. The sociodemo- toms. It consists of 140 items, which graphic and clinical variables recorded were systematically cover all the phenomena likely to age, sex, marital, employment, and living sta- be relevant when conducting a mental state tus. The seizure variables included age of examination. An important feature is that, onset, duration, frequency, time of occur- although certain initial
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