Affective disorders and anxiety

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As is the case for psychoses, it is also true for the affective disorders that the usual psychiatric diagnostic categories do not offer adequate classification for epilepsy patients. Typical constellations of symptoms allowing the diagnosis of a 'major' depressive episode are rare, dysthymic or 'organic' depressive states rather frequent.

Blumer and Altshuler (1997) have attempted to introduce a useful classification category of affective disorders in patients with TLE, which they call 'interictal dysphoric disorder'. Predominant features are, among others, depressive mood, paroxysmal irritability leading to outbursts of verbal aggressivity with consecutive feelings of shame, a sudden onset and a brief duration of only days.

Blumer et al. (1998) found that those interictal dysphoric mood disorders -present in 57% of their patients - faded away after surgery in 20% of patients, 36% stayed stable with their dysphoric disorder, and 44% worsened after surgery, some with a remission after antidepressant treatment. There were also about 40% of the psychiatrically intact group, predominantly those who continued to have seizures, who developed their dysphoria after surgery.

The enduring remittance of depressive symptoms depends on complete seizure relief (Blumer et al., 1998; Hermann and Wyler, 1989). This finding is supported by our results. Moreover we found that our preoperatively depressed patients showed differences in psychopathology after surgery related to laterality: dominant resections led to somatoform symptoms as surrogates of depression (headache, backache, etc.), while nondominant resected patients frequently had postoperative depressions.

Emotional irritation and lability with sudden mood changes, uncertainty concerning the future, reduced stress tolerance etc. during the first months after ES are very typical (41% of all resected patients, Fraser 1988; 45% during the first 6 weeks, Ring et al., 1998).

Additionally, circumscribed episodes of depression occur after ES. As early as in 1957 Hill et al. described their occurrence, being independent of seizure outcome, with a remission within the first 18 months after surgery. Because of their temporary character, Trimble (1992) designates them as 'complications of surgery'. Their frequency is about 8-10% of surgically treated patients (Naylor et al., 1994). They occure more with nonlesional resections or mesio-temporal scleroses (Bruton, 1988), in nondominant resected patients (Fenwick et al., 1993; Bethel) and in preoperatively aggressive patients, who lose their aggressiveness after surgery and tend to develop depressions (Taylor, 1987). There are hints from one research group (Kanemoto et al., 1998) of correlations with dominant resections and with post-ictal psychoses before surgery. The occurrence of postoperative depression was found to be independent of seizure outcome (Hill et al., 1957), except for psychi-atrically preoperatively intact patients in whom depression seems to be linked to seizure recurrence (Blumer et al., 1998). For an overview see Table 18.4.

Mania seldom occurs in patients with TLE (Wolf, 1982). However, with respect to postsurgical outcome there are some hints for the occurrence of manic syndromes. Krahn et al. (1996) describe hypomanic states immediately after

Table 18.4. Episodes of postoperative depression

Duration

Remission within 18 months (Hill et al., 1957) Aetiological hypothesis

Process of scarring (Trimble, 1992) Frequency

8-10 % of resected patients (Bruton, 1988; Naylor et al., 1994; Bethel) Morphology

Mesio-temporal sclerosis or nonlesional resections (Bruton, 1988) Laterality

Nondominant resections (Fenwick et al., 1993; Bethel); dominant resections (Kanemoto etal., 1998) Psychiatric predictors

Aggressivity leads to postoperative depression (Taylor, 1987); postictal psychoses leads to postoperative depression (Kanemoto et al., 1998) Seizure outcome

Independent occurrence (Hill et al., 1957; Bethel)

surgery and Kanemoto et al. (1998) reported about 10% of the resected patients showing (hypo)manic episodes directly after surgery. It may well be that the incidence of manic disorders is usually underestimated because of two different reasons: (1) the differentiation between optimistic gladness after successful resection and symptomatic euphoria is difficult in some cases; (2) manic symptoms may have already vanished and may not be remembered at the time of the first postoperative evaluation, which in many centres takes place at 3 or 6 months after surgery.

Symptoms of anxiety are very common in epilepsy patients, but their classification covers many problems of differentiation between fear of seizures, fear as a symptom of seizures, avoidant behaviours due to stigmatization, fear as a symptom of depression, and others.

Accordingly, preoperative estimations of anxiety disorders in candidates for surgery vary between 10% (Manchanda et al., 1996) and 44% (Bladin, 1992). More than 2 years after surgery Koch-Weser et al. (1988) even found higher rates of anxiety than before surgery.

Ring et al. (1998) reported a frequency of 42% of early postoperative symptoms of anxiety which had already diminished after 3 months. In the early weeks after surgery, an exact differentiation between the woven symptoms of irritability, anxiety, and mood fluctuation is not easy and might even be impossible. This time period deserves to be better evaluated from the psychopathological perspective.

Table 18.5. Postoperative nonepileptic attacks

Frequency

10% (Glosser et al., 1999); 5% (Ney et al., 1998); 4% (Bethel) Preferred incidence Gender

Women (Glosser et al., 1999; Bethel) Laterality

Right (Glosser et al., 1999; Bethel); Left (Ney et al., 1998) Onset-time

After adolescence (Glosser et al., 1999) Preoperative psychopathology High (Ney et al., 1998); Borderline personality disorders (Bethel)

Low (Ney et al., 1998) Operative complication rate High (Ney et al., 1998)

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