Amarouche, M; (2008) Organic mental disorders (other than memory disorders, depression and psychosis) after temporal lobe epilepsy surgery. Doctoral thesis , UCL (University College London).

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Abstract

Epilepsy is one of the commonest neurological diseases (Hauser & Kurland 1975). Despite medical advances in treatment, 30% of focal epilepsies remain intractable to anti-epileptic drugs (Spencer 2008). The resective surgical alternative in patients with temporal lobe epilepsy (TLE) offers a good rate of long-term seizure freedom (Shorvon 2005) but is also often the source of postsurgical psychiatric and behavioural disturbance. The great majority of studies in this area have focused on depression, anxiety and psychosis, and memory disturbance. The occurrence of other organic mental disorders (OMDs) is often ignored. These disorders are generally underdiagnosed. This is because, pre-operative and post-operative psychiatric assessment is often overlooked, because of the lack of standardised classification (and hence vocabulary to describe these conditions) and a lack of sensitive psychological instruments to detect these conditions. Two main instruments are widely used in psychiatry for the classification of OMDs (LM, DSM-IV, and ICD-10). None is specific to epilepsy and epilepsy surgery. A third classification - the Lindqvist- Malmgren (LM) - has been proposed and is beginning to be used particularly in epilepsy circles. Aims: This thesis has 4 main aims -to describe the LM diagnostic system for organic psychiatry and contrast it with DSM-IV and ICD-10 (Aim 1) to review the occurrence and type of OMDs after TLES in the literature (Aim 2) to define the existence of an 'ideal' classification for use in studying the OMDs due to TLES (Aim 3) and to outline the structure of a pilot questionnaire for use in the evaluation of the range and extent of OMDs that occur following TLES and the design of a future research project to use in such evaluations (Aim 4). Methods: the information for this thesis was extracted from a database search of the literature of the last 40 years and from a scrutiny of the reference lists of all the relevant papers. It also relies on the interview of Professors Helge and Kristina Malmgren conducted in Sweden as part of data-gathering. Results and discussion: Aim 1: The LM scheme is poorly documented in the English literature. It is based on an etiologically neutral approach and individualises 6 main OMDs, the most important being the Astheno-Emotional Disorder. Several of its important categories have no equivalent in the DSM-IV and ICD-10 (including Astheno-Emotional Disorder, Emotional-Motivational Blunting Disorder, and Hallucination-Coenestopathy-Depersonalisation Disorder) and the categorization differs in terms of diagnostic criteria and the specification of individualised disorders. Aim 2: OMDs are rarely assessed in the course of TLES and there is a surprising dearth of cases documented in the literature, in spite of their frequent occurrence and potential importance. Where they have been reported in the literature, the diagnostic scheme used has varied (or indeed is often not specified). The reported cases from the literature review can be divided into 8 main categories: Astheno-Emotional and Emotional Motivational Blunting Disorder, interictal dysphoric disorder, mood disorders, obsessive-compulsive disorders, personality disorders, behavioural disorders, sexual disturbances, suicide and suicide attempts. Aim 3: None of the currently available classifications is considered 'ideal' in the study of the occurrence and range of OMDs following TLES. However, a modification of the LM scheme is the most likely to fulfill this condition. The suggested modifications can be amended to the existing classes of OMDs or integrated as new disorders and should include, for instance, the interictal dysphoric disorder, personality disorders and the Bear and Fedio traits (Bear & Fedio 1977). Aim 4: A suggested pilot questionnaire is proposed which explores the previously mentioned 8 OMDs categories individualised by the review of the literature as being consequences of TLES. A prospective longitudinal controlled study is the most powerful design for the assessment of the occurrence and range of OMDs after TLES. This is designed to proceed in two stages. In the first, the questionnaire should be finalized and validated. The second stage will incorporate the pilot questionnaire administered during semi-structured psychiatric interviews for both TLES candidates and a non-operated control group examined on 4 occasions (in the operated group, pre-operatively and 6, 12 and 24 months after surgery). The results will then be compared within the same patient pre- and postoperatively, and in the control group based on serial prospective scores.

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