Neuropsychiatry of Epilepsy
Emotion, perception, and cognition are all processed within specific networks of the brain. Environmental forces, such as stressful life events, psychological trauma, and social injustice may impact these networks. Biological forces, including hormones, metabolism, genetics, and brain health interact with environmental forces to shape how we feel. Brain injury from epilepsy, stroke, traumatic brain injury, Parkinson’s disease, Alzheimer’s disease, and multiple sclerosis may directly affect specific networks that modulate emotions. For instance, Parkinson’s disease is a chronic degenerative condition that affects subcortical networks; therefore, mood disorders often manifest as depressed mood, anhedonia, apathy, and psychomotor slowing. In contrast, epilepsy is a paroxysmal condition (seizures come and go) that primarily affects frontal temporal networks; therefore, mood disorders often manifest as mood lability, suicidality, and disinhibition, and anticipatory anxiety (an intense fear that a seizure may occur at any time).
Epilepsy is one of our primary areas of focus. People with epilepsy suffer from depression, anxiety, and/or psychosis. Sometimes emotional distress is driven by poorly controlled seizures, psychosocial conditions, and/or changes in neurocircuitry. Our work has studied how epilepsy treatment, both medication and surgical interventions, affect psychiatric outcomes. While most research suggests that only seizure freedom (not simply seizure reduction) improves quality of life, our lab demonstrated that improved seizure control (even if seizure freedom is not achieved) is associated with improved mood and anxiety symptoms as well as quality of life. However, our work also demonstrated that some people with seizure freedom after successful epilepsy surgery are still up to 12 times more likely to die from suicide than the general population.
The high risk of emotional distress, mental illness, and suicide in people with epilepsy underscores the importance of comprehensive neuropsychiatric care. Due to Dr. Hamada Altalib’s clinical commitment to managing epilepsy, most of the Altalib Lab’s work in neuropsychiatry is related to epilepsy neuropsychiatry. However, the lab has and continues to collaborate with other investigators on other neuropsychiatric conditions such as traumatic brain injury, chronic migraines, multiple sclerosis, etc…
Functional (psychogenic non-epileptic) seizures
Intense stress, including psychological trauma, may rewire the emotional circuits of the brain leading to functional neurological symptoms or disorders. Older terms for these symptoms include “conversion” or “somatization” disorders. Functional neurological symptoms may manifest like any neurological condition, however, the most common symptoms are functional tremors, weakness, gait/walking imbalance, and seizures. People who suffer from functional neurological disorders cannot control their symptoms (they are not faking the symptoms) and often receive extensive diagnostic testing and inappropriate treatment. For instance, many people who psychogenic non-epileptic seizures (PNES) carry the diagnosis of epilepsy, are misdiagnosed, and are inappropriately treated with (sometimes multiple) anti-seizure medications. Given Dr. Altalib’s background in epilepsy and neuropsychiatry, the Altalib Lab has collaborated with other investigators to develop models for delivering psychotherapy for people with PNES. The Altalib Lab has developed a natural language and machine learning tool to identify cases of PNES from the electronic health record. With the support of DoD funding, the lab designed a retrospective cohort study from the VA electronic health record and is currently analyzing PNES outcomes among Veterans.
Long-term Association Between Seizure Outcome & Depression After Resective Epilepsy Surgery:
This multicenter prospective study explored the association between long-term epilepsy surgery outcome and changes in depressive symptoms. The extent of depressive symptoms and depression case status (none, mild, or moderate/severe) were assessed using the Beck Depression Inventory (BDI) preoperatively and 3, 12, 24, 48, and 60 months postoperatively. A mixed-model repeated-measures analysis was performed, adjusting for covariates of seizure location, gender, age, race, education, and seizure control. Although study participants had initial improvement in depressive symptoms, on average, after resective surgery, only patients with good or excellent seizure control had sustained long-term improvement in mood.
Long-term association between seizure outcome and depression after resective epilepsy surgery
Mood, anxiety, and incomplete seizure control affect quality of life after epilepsy surgery:
We examined the complex relationship between depression, anxiety, and seizure control and quality of life (QOL) outcomes after epilepsy surgery. A mixed-model repeated-measures analysis was used to analyze associations of depression, anxiety, seizure outcome, and seizure history with overall QOL score and QOL subscores (cognitive distress, physical health, mental health, epilepsy-targeted) prospectively. Seven epilepsy centers enrolled 373 patients and completed a comprehensive diagnostic workup and psychiatric and follow-up QOL evaluation. Depression and anxiety are strongly and independently associated with worse QOL after epilepsy surgery. Interestingly, even partial seizure control, controlling for depression and anxiety levels, improved QOL.
Surface plots demonstrate the relationship between quality of life (QOL) and depression scores (Beck Depression Inventory [BDI]) over time. The z-axis provides QOL T scores and color codes lowest scores blue to highest scores red. The x-axis shows changes in QOL and BDI over time in months, with the 0 point designated as the presurgical evaluation. The y-axis shows the BDI scores, with high scores indicating more severe depression. Figure parts A, B, C, and D represent subjects with excellent, good, fair, and poor seizure control, respectively. The scatter plots clearly show more dark red, reflecting better QOL, in subjects with better seizure control. Furthermore, with the exception of fair seizure control, the QOL improves (becomes more red) with time. Finally, there is improved QOL with lower BDI scores across each level of seizure control.