Postictal Psychosis

Michael Trimble and Bettina Schmitz (edt)

Behavioural correlates of frontal lobe epilepsy

Mon, 02 Jan 2012 17:44:40 | Postictal Psychosis

If we propose problems with behaviour selection/initiation and inhibition as a functional complex which is mainly affected in frontal lobe epilepsy, the obvious question is whether or not this dysfunction has a correlate in personality and behaviour.

With respect to this question we applied several self-rating scales to a group of 95 patients with either frontal (n= 18) or mesial temporal lobe epilepsy (n = 77). Epilepsy groups were matched regarding sex, the age at the onset of epilepsy (mean 11 years) and the duration of epilepsy (mean 24 years). The tests in use were the BPSE 'activity subscale' assessing frequencies of activities (Helmstaedter and Elger, 1994); depression and anxiety were assessed by the Beck Depression Inventory (BDI; Beck et al., 1981) and the Zung Self Rating Anxiety Scale/SAS (Zung, 1971); personality was assessed by the Neo Five Factor Inventory, a German version of the NEO personality inventory (Costa and McCrea, 1992). Quality of life in epilepsy was assessed by a German modified QOLIE-10 (English version: Cramer et al., 1996); and finally we evaluated education and employment in order to add some objective data.

Group comparisons considering localization and lateralization of epilepsy revealed only slight differences (Table 12.5). Patients with mTLE as a trend showed poorer mood and significantly increased anxiety scores, they described themselves as more active at home, less active with respect to outdoor cultural activities, and less open for experiences than patients with FLE. It is important to note that, when compared to normative data of healthy control subjects, the result regarding outdoor cultural activities must be interpreted in a way that patients with FLE are more active than the controls and patients with mTLE. Furthermore, when compared to data of a healthy control group, the neuroticism score of patients with mTLE and the conscientiousness score of patients with FLE appeared elevated.

As regards quality of life (QOL), patients were categorized as having poor QOL when they showed scores below the 25th percentile. As is shown in Figure 12.2 patients with TLE generally tended to report poorer QOL than patients with FLE.

Table 12.5. Group comparisons considering localization and lateralization of epilepsy

Scale

Group

Mean

Significance

Mood (BDI SAS)

Depression

FLE

7.6

7.3

n.s.

mTLE

11.1

9.0

Anxiety

FLE

29.7

7.9

mTLE

35.9

7.4

Activities (BPSE: activity subscale)

Home activities

FLE

25.3

4.9

mTLE

27.8

5.7

Social activities

FLE

20.2

5.3

n.s.

mTLE

18.7

6.1

Cultural activities

FLE

16.3

6.5

mTLE

12.8

5.4

Personality (NEO FFI)

Neuroticism

FLE

21.4

5.4

n.s.

mTLE

24.7

7.4

Extraversion

FLE

26.2

4.3

n.s.

mTLE

26.0

6.2

Open to experiences

FLE

28.6

6.6

mTLE

25.1

5.3

Agreeableness

FLE

31.6

4.6

n.s.

mTLE

30.2

4.2

Conscientiousness

FLE

34.9

5.6

n.s.

mTLE

33.2

5.3

FLE, frontal lobe epilepsy; mTLE, mesial temporal lobe epilepsy. For decriptions of scales used, see text. a Significantly different; n.s., not significantly different.

Impaired mood, memory problems and social limitations correspond well to the features of TLE found with the other instruments in this evaluation.

Our current approach to behavioural problems and personality in patients with focal epilepsies is less led by classification systems, which may be useful in idiopathic psychiatric disorders. As already mentioned in the introduction, there is a long history of personality research in epilepsy and up to now no consistent features have been discerned. So far this has been explained by the multifactorial determination of psychiatric problems in patients with symptomatic epilepsies. As

quality of life items
energy	y	b		□frontal ® mesial
mood	i......]..................]......*
mobility	F—				temporal
memory difficulty				*
work limitation	i
	—,———i
social limitation	i-1.........1—i
physical AED effect	---—hi
mental AED effect	■.....p—		'IS *
seizure fear	-:-^
overall

0% 10% 20% 30% 40% 50% 60% 70% Impaired QOL [25% percentile]

Figure 12.2. Quality of Life (QOL) in frontal lobe epilepsy (FLE) as compared with mesial temporal lobe epilepsy (mTLE). Values < 25th percentile were considered as reflecting perception of impaired QOL. Asterisks indicate significant group differences in Chi-square testing. AED, antiepileptic drug.

far as psychometric approaches are concerned previous studies of temporal lobe epilepsy mostly used the MMPI (Rose et al., 1996) or more specifically the Bear-Fedio Inventory (Bear et al., 1982; Devinsky and Najjar, 1999). It is our daily experience that commonly used psychiatric scales or psychological personality inventories largely fail to reflect objectively what seems to the examiner clearly to be an epilepsy-related change in personality or a behaviour disorder.

At the moment we are evaluating our own clinical personality inventory, which was empirically designed according to a collection of behavioural problems perceived by the clinical psychological staff in the University Hospital of Epileptology in Bonn, Germany (Helmstaedter et al., 2000«). For preliminary analysis the questionnaire was consecutively applied to 59 patients with TLE, 17 patients with FLE, 9 patients with parieto-occipital epilepsy and 44 healthy controls. It consists of 82 questions concerning 15 different behavioural domains. The answer style is a six-stepped frequency of occurrence rating with 1 = 'occurs not at all' and 6 = 'occurs very frequently'. Second order factor analysis resulted in six factors, which were interpreted as follows: 1. 'organic personality change' with patients reporting communication problems, emotional lability, being indecisive, susceptible to interference, perseverative and hypoactive; 2. 'depressed mood' including depressive mood, reduced vitality, anxiety, and insensitivity; 3. 'addiction and obsession' including addiction to legal and illegal substances, compulsion, and obsession;

Scale	Impairment < 1 SD	Lateralization 37 right/48 left	Localization 59 T/17 F/ 9 P	Sex 59/70	Pathology 28 with AHS
1. Organic personality change	32%**	LEFT*	TLE/FLE*	W > M	/
2. Addiction/obsession	20%*	RIGHT*	FLE*	/	/
3. Depressed mood	28%	/	/	/	AHS (right)*
4. Extraversion	32%**	LEFT/RIGHT*	PLE*	/	/
5. Aggression	31%**	LEFT*	/	/	/
6. Adaptivity/hyperactivity	29%*	/	FLE*	/	/
P < 0.05, *P < 0.01 (significantly different from control subjects)

Figure 12.3. Results obtained with the clinical personality questionnaire. TLE, temporal lobe epilepsy; FLE, frontal lobe epilepsy; PLE, parieto-occipital epilepsy.

4. 'extraversión' comprised sociability, curiosity and self-determined behaviour;

5. 'aggression' comprised aggression, sensation-seeking, nonadaptive behaviour and violence; 6. 'hyperactivity and adaptivity'. When taking clinical data as well as sex as independent variables some interesting and comprehensible results could be obtained (Figure 12.3).

The data first of all indicate that problems in the respective areas are evident in 20-30 % of patients. Organic personality changes are preferentially seen in left epilepsies of either origin, in women more than in men. Addiction and obsession are more frequent in right epilepsies and in frontal epilepsies in particular. Depressed mood is preferentially seen in patients with hippocampal sclerosis, a finding which is in line with one of our recent publications (Quiske et al., 2000). All patients and patients with parietal epilepsies in particular show reduced extraversion. Aggressive behaviour seems more frequent in left epilepsies, and patients with FLE show increased hyperactivity and adaptivity, which may parallel the finding of increased outdoor/cultural activities and openness for experiences. It is important to note that these results are preliminary and that larger control groups and validation studies are still required. However, the data indicate that the often-cited depressive mood is not the only behavioural problem in patients with focal epilepsy, and that apart from this there are specific behavioural aspects which appear related to localized and lateralized lesions or epileptic dysfunctions.

Although no differences between patients with FLE and TLE were obtained, it is worth reporting the results with regard to the organic personality change scale in more detail. As shown in Figure 12.4 for selected items, about 20% of the patients report that they offend others; between 20 and 35% of the patients report problems

Organic personality change

Offends others

Receptive problems

Perseverative

Misunderstandings

Circumstantial

Irritates others

% deviant ratings > 75% percentile as compared with healthy controls

Figure 12.4. Items extracted out of the 'organic personality change' scale of the clinical personality inventory. Bars represent the per cent of patients with focal epilepsies reporting increased problems in communication and interpersonal contact.

with reception, misunderstandings, that they were perceived as perseverative or circumstantial; and 50% report that their behaviour irritates others. This is similar to the 'epileptic personality', and taken together with the depressed mood, one might well think of the dysphoric and paroxysmal mood disorder as it has been proposed from a more psychiatric point of view (Blumer, 2000).

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