Neuropsychiatric Symptoms of Epilepsy

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G. Rayner and S.J. Wilson
Rare Neuropsychiatric Symptoms Surrounding Adult Epilepsy Surgery
Occasionally in the epilepsy literature, small case series or case studies appear
to report on the more unusual neuropsychiatric symptoms and disorders that
may emerge or resolve after epilepsy surgery in adults. These include apparent
improvements in pathological rage after surgery [ 106 , 107 ], exacerbation
or remission of obsessive-compulsive features [ 86 , 108 , 109 ], development of
a profound tic disorder [ 110 , 111 ], emergence of pathological or intrusive
hypersexuality ([ 111 , 112 ]; see also Case Vignette 2 ), as well the development
of de novo postoperative mania ([ 53 ]; n = 16). These studies provide initial
evidence that epilepsy surgery can impact on more uncommon neuropsychiatric
conditions, however the small case numbers limit our understanding of
the underlying mechanisms that might give rise to these patterns of behavior
following surgery.
The Process of Psychological Recovery After Epilepsy Surgery
Regardless of the personal attributes and coping skills of the individual, epilepsy
surgery typically invokes a process of significant psychological adjustment. This
process may be most intense in the 3–6 months immediately following surgery, but
longer-term follow-up studies suggest that psychological adaptation and reorientation
continues to evolve for at least the first 24 months. In particular, research
groups from the United States and Australia have carefully mapped the psychiatric
sequelae of epilepsy surgery and shown that the first 24 months can be broadly
divided into three phases of recovery [ 50 , 59 , 113 ].
An initial, medically focused phase occurs while the patient is recuperating in
hospital from the physical stressors of neurosurgery. For patients with premorbid
psychiatric vulnerabilities, any surgical complications or an early recurrence of seizures
may trigger a decline in mental state, as seen in the emergence of PNES in
patients with preexisting psychiatric diagnoses. Most patients, however, do not
experience surgical complications and are focused on becoming well enough to be
discharged from hospital.
Once home, the recovery period spanning 1–6 months post surgery can take
several forms. Patients who are seizure-free must adapt to the sudden ablation of a
pervasive and disabling condition that has often been present since early childhood
[ 114 ], and essentially learn to be “normal.” At the core of this lies a change in the
patient’s self-concept that can require adjustment across multiple life domains (see
Table 17.3 ). Adaptation also takes place in the context of any “agendas” or expectations
that patients and their families bring to surgery [ 114 ]. The weight of the
changes expected from patients can sometimes lead to maladaptive behaviors that
can undermine the potential benefits of seizure freedom. This process of adjustment
and its pitfalls have been previously well characterized as the burden of normality
[ 19 , 59 ].