Psychiatric disturbance and personality change after epilepsy surgery

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Epilepsy surgery carries a risk of precipitating psychiatric disturbance. The most common problems are mood swings, anxiety and depression. These are seen in 20-30% of people who undergo surgery for epilepsy. Although distressing, these are generally mild and remit within weeks or months, although some people may need antidepressant medication or counselling.

More severe psychiatric breakdown may also occur. In a recent study of subjects who had undergone epilepsy surgery in London, about 10% of patients undergoing temporal lobectomy suffered a depressive or psychotic episode after surgery of a severity that required hospitalization, and many more needed consultation and treatment. Compounding these problems is the fact that no pre-operative risk-factors have been identified that reliably predict postoperative psychiatric disturbance. The lack of pre-operative psychopathology does not seem to protect against postoperative anxiety or depression. There is also no clear relationship between psychiatric disturbance and either the lateralization of the operation or the nature of the pathological tissue.

The occurrence of personality change after surgery is a poorly studied subject, but one of great concern. Various changes have been well documented, but their frequency and the factors predictive of risk are largely unknown. Well recognized are changes in sexuality (usually hyposexuality), emotionality (flattening of emotional responses), impulsiv-ity and obsessive-compulsive disorders. Anxiety, depression, personality change and psychotic breakdown can also occur after temporal lobe resections.

Counselling patients in this situation is difficult. In general patients, particular caution must be communicated to patients with a strong past or family history of psycho-pathology, as they have inherent biological vulnerability. While it is not clear if co-morbid psychopathology per se increases the risk of post-operative psychopathology, the burden of surgery is likely to be greater in someone who has an ongoing psychiatric illness. Also, candidates for surgery with poor psychosocial support, strained personal and familial circumstances, poor understanding of the process or unreasonable expectations are especially likely to develop post-operative psychopathology.

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