Book Review
Neuropsychiatry
The Neuropsychiatry of Epilepsy. Michael Trimble, Bettina Schmitz, editors. Cambridge (UK): Cambridge University Press; 2002. 350 p. US$55.00.
Reviewer
rating*: Excellent
Review by: Erwin K Koranyi, MD, FRCPC
Ottawa, Ontario
Since the publication of Russell J Reynolds’ classic monograph on epilepsy in 1861 (1), a mere 4 years after Charles Locock introduced his bromide treatment, almost every decade has seen a fresh treatise on this condition. Many of these publications were multiauthor books. An editor of this current book, Michael Trimble, is a respected old hand in his contributions to epilepsy literature for at least 22 years (2). In this work, many new ideas are presented and discussed with clarity.
The monograph is divided into 6 parts and contains 22 chapters covering all aspects of the topic. As with many multiauthor publications, a couple of chapters lag behind the expectation. However, most contributions are outstanding and contain valuable information, and most are written by well-recognized European and American experts on the topic.
In the first chapter, ES Krishnamoorthy presents his views on the epidemiology of epilepsy and its current classification. He regrets the lack of attention previous classifications paid to the etiology and pathophysiology of mental disorders occurring in epilepsy. In 13 pages, he touches on a wide range of issues.
J Engel Jr, C Wilson, and F Lopez-Rodrigez write an extremely important and well- organized chapter on the issue of limbic connections, inspiring one to buy the book for this chapter alone. They elaborate on the differentiation of the immature brain and plastic changes caused by kindling and on the epilep- togenics of amygdala; they further explain what used to be called the “temporalization” of epilepsy. The authors explain with unique clarity the hippocampal connections and memory pathways and the “dentate gate” that prevents seizures.
Dieter Janz elaborates on the clinical manifestations of the psychiatric morbidity found in epilepsy: the ictal, postictal, and interictal psychoses and their symptomatology. The relation between seizures and patients’ sleeping habits are highlighted. Cesare Maria Cornaggia and Giuseppe Gobbi follow with detailed information about frequent learning difficulties.
Ludger Tebartz van Elst wrote a fascinating chapter on the old issue of aggression in epilepsy. He deals with 2 kinds of aggression in humans: first, the predatory aggression, with a well-structured, goal-directed, emotionally calm and concentrated state of mind; and second, a defensive–aggressive amygdaloid aggression with high emotional arousal, fear, anger, and vocalization. Different authors consider aggression in epilepsy patients to be rare (occurring in 7% of patients) or frequent (occurring in 50% of patients). Aggression in temporal lobe epilepsy and explosive disorder is discussed, along with their medical and psychiatric treatments.
Dietrich Blumer, another international expert and old-timer in neuropsychiatry, discusses the difficult issue of suicide: the occurrence rate of suicide is 5% among epilepsy patients, vs 1.4% among the general population. Temporal lobe epilepsy has a suicide rate of up to 25%, which is fiftyfold the expected rate. The role of interictal depression and Landolt’s concept of forced normalization are discussed. The frequency of suicide and the type of medication used to control the seizure disorder is discussed, showing an excess of suicides among those who were treated with barbiturates.
Kousuke Kanemoto writes on the topic of postictal psychosis and other psychotic manifestations of epilepsy, particularly those that occur in medial temporal lobe lesions with an additional neocortical involvement. Several chapters discuss cognitive decline and dementia in patients with epilepsy, temporal lobe epilepsy, and the less frequent cases of frontal lobe epilepsy. Howard A Ring and Nuri Gene-Cos draw parallels between epilepsy and panic disorder by pointing to their similarities: both are paroxysmal in nature and both involve the same neurochemical substance of the GABA system; the frequent depersonalization and derealization seen in both are similar. Magnetic resonance imaging (MRI) studies demonstrated abnormalities in the mesiotemporal area in both conditions.
An important chapter by Bettina Schmitz details the effects of antiepileptic drugs on the patient’s behaviour. This chapter deals with drug treatments and is very important for the clinician. Albert P Aldenkamp’s drug treatment of epilepsies is also an important chapter. Steffi Koch–Stoecker reviews the outcome and psychiatric effects of surgery for temporal lobe epilepsy. Although seizure free, the patient may stay disabled. The psychiatric comorbidity of surgical candidates is very high, from 43% to 80%, because the mesiotemporal structures are involved. Postoperative psychoses occur in about 7% to 16% of cases, and owing to forced normalization, de novo psychoses occur among 0.5% to 21%; Trimble’s statistics show a rate of suicide of 3.8% to 35.7%. While postoperative mania is rare, depressive episodes often occur after surgery. Symptoms of anxiety are common, with 10% to 44% of surgical candidates experiencing them. Personality disorders are seen among 60% of candidates and might show deterioration after surgery.
Christian Elger and Christian Hoppe present an interesting chapter on vagus nerve stimulation. Though it has been known since 1938 that vagus nerve stimulation suppresses epileptic activity, this treatment was not applied clinically until 1988, when a pulse generator was implanted in a patient’s chest. Such treatment led to improved quality of life in 50% to 60% of patients who underwent the procedure. Subsequently, the significant improvement in patients’ depression led to the application of vagus stimulation in a population of nonepileptic patients who were suffering from intractable depression.
Mr Trimble and Anke Hensiek write a fascinating and useful chapter on the application of psychotropic drugs in patients with seizure disorder. Antidepressants, particularly tricyclic drugs, are seizurogenic and myoclonic, and other seizure forms are provoked in 40% of the patients, with seizures appearing 24 hours to 1 week after drug ingestion. The drugs that are most seizure-inducing in this category are clomipramine, amitriptylene, and quadricyclic maprotyline. Particularly prone to seizures are individuals with a family history of epilepsy or who have suffered a head injury or cerebrovascular accidents. All selective serotonin reuptake inhibitors have been associated with seizures; sertraline provokes seizures and citalopram less so. Paroxitene is the most frequently used antidepressant in epilepsy, and according to Trimble, some epilepsy patients became seizure-free on paroxitene. It does not cause interactions with antiepileptic drugs. Nowadays, the atypical antipsychotics are used most often because they have fewer effects than the older drugs on the seizure threshold. Seizures occur with clozepine and are dosage related. Benzodiazepines may cause a paradoxical increase of seizures. Lithium is also proconvulsant.
There is a chapter on psychotherapies with epilepsy patients by Martin Schondienst, who found seizure-related outcomes showing some improvement. Psychotherapies in epilepsy, except in cases of pseudoseizures, were not the subject of much research. A final chapter by Caroline E Selai, Katja Alstner, and MR Trimble describes a scale auditing a patient’s health profile, including their physical, psychological, and social problems. The Quality of Life Assessment Schedule is described in detail.
The book is written in a plain, easy-to-read style. It is bound in an attractive soft cover. For the amount of information the text provides, it is a bargain.
References
1. Russell RJ. Epilepsy: its symptoms, treatment and relation to other chronic convulsive diseases. London (UK): John Churchill; 1861.
2. Trimble MR. The interictal psychoses of epilepsy. In: Benson F, Blumer D, editors. Psychiatric aspects of neurologic disease. Volume II. New York: Grune & Straton; 1982.
*Reviewer
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