M.R. Trimble1 and B. Schmitz2
1 Institute of Neurology, London, UK
2 Humboldt University, Berlin, Germany
In 1997, Dr Pete Engel, President of the International League Against Epilepsy, invited us to establish a commission on psychobiology, and this book represents one of the achievements of the commission's work. The task of the commission was to explore the interface between epilepsy and behaviour disorders, from a biological and social point of view. To these ends a number of subcommissions were established, and their task was to explore the existing knowledge base of the discipline, to suggest research strategies for interventions and to educate both patients and carers about aspects of epilepsy which a number of people consider to have been neglected.
The present book is divided into several parts, covering a spectrum of clinical topics which have been of concern to the commission. Some old chestnuts, for example the interictal psychoses of epilepsy, have not been allocated specific chapters, and a number of other areas, particularly relating to learning disability, cognitive decline, dissociative attacks and vagus nerve stimulation have been included. It is hoped that by expanding upon the literature on some of these less-well-discussed aspects of psychobiology in epilepsy further interest will be stimulated, leading to both intellectual discussion and research endeavours.
We start our text with an introduction to the classification of psychiatric disorders in epilepsy. The point is made that existing classifications used in psychiatry such as the DSM-IV are quite inadequate when it comes to dealing with the subtleties of the behaviour changes of patients with neurological disorders.
We then discuss the biological underpinnings of some behaviour problems, in terms of exploring the limbic system and related structures that are affected by the process of epilepsy and which are also related to behavioural disorders.
The part on clinical aspects explores in particular the problems of learning disability, and introduces the important area of state-dependent learning disabilities: patients with cognitive deficits that can be profoundly reversed by appropriate treatment strategies. Other important areas covered include the ever-controversial topic of aggression, the importance of suicide, and the group of psychoses that occur postictally.
The next part looks further at cognitive problems in patients with epilepsy, examining whether the concept of dementia is relevant, discussing the question as to whether or not there is cognitive decline in patients with various types of epilepsy over time, and also examining the issue of frontal lobe epilepsies. The latter have been well defined from the seizure point of view in recent years, but the behavioural and cognitive associations have yet to be clarified.
We make no apology for including a section on nonepileptic seizures. The fact that many patients who are diagnosed as having epilepsy do not have epilepsy, but have some form of nonepileptic attack disorder (pseudoseizure) is now well recognized. This problem has been around for centuries, and such eminent neurologists as Charcot have spent some considerable time attempting to differentiate between nonepileptic and epileptic seizures. However, this often still proves difficult. We still have inadequate information as to the mechanisms for the development of nonepi-leptic attack disorder, and these, and the possible biological associations, are taken up in this section.
The final sections deal with treatments and their side effects. Of importance in this section are the references to surgery, not only temporal lobe resection, but also more recent advances such as vagus nerve stimulation. The beneficial and negative psychiatric consequences of these treatments are at the present time being actively explored, and some early work is presented here. However, in the context of psychobiology, our treatment strategies must go beyond medication and surgical interventions, and we include a discussion of psychodynamic principles in relationship to the management of epilepsy, and also a chapter on quality of life.
We, the editors, hope that the book will enliven the debate about the links between epilepsy and behaviour, an area which is often not well discussed, partly because of some worry that any association between psychiatry and epilepsy may stigmatize patients with epilepsy even more than they already are. However, the problems that we have identified are a reality not only in the clinic, but also for patients and carers themselves. It is difficult to define treatment and management strategies if problems are ignored, and so our intention is to enliven this area with these up-to-date reviews on behavioural and cognitive problems in epilepsy, and their social and biological underpinnings.
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