Neuropsychiatric Symptoms of Epilepsy

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G. Rayner and S.J. Wilson
In the third phase of rehabilitation spanning 12–24 months post surgery, patients
often attempt to reconcile their changed psychological and seizure status. One study
that followed 89 patients for 24 months following ATL revealed two distinct patient
pathways [ 59 ]. The majority of patients (58 %) reported good outcomes, characterized
by improved family dynamics, enhanced vocational and social functioning, and
driving by 24 months post surgery. A range of trajectories led to these outcomes,
including the experience of early postoperative adjustment difficulties. Case
Vignette 2 illustrates the case of a young mother who eventually attained a good
outcome from surgery, after overcoming adjustment difficulties and depression in
the early postoperative phase. As in the study by Wilson et al. [ 59 ], resolution of
early anxiety and vocational change at 12 months were indicators of a good outmother
and sister, and significant vocational and social limitations she attributed
to being unable to drive. She was deemed to have features of a moderately
severe depression, and at high risk for a further worsening of her mood
post surgery. She was commenced on citalopram.
Postsurgery Follow-up . Within a few weeks of surgery family members
witnessed a return of focal dyscognitive events, albeit at a reduced rate. She
was irregularly compliant with both her antiepileptic and antidepressant medication,
and her mood remained low and variable. While disappointed at one
level by the postoperative events, at the 3-month review N.M. described some
sense of “comfort” in the familiarity that she ascribes to her seizures (e.g., a
feeling akin to “finding a child who you have lost at the shops”). She continued
to struggle with the increased expectations others had of her. Against a
background of disrupted education, limited vocational opportunity, and a
recent failed personal relationship, N.M. was struggling to make future plans.
The situation was complicated by family relationships characterized by high
levels of conflict. Despite this she continued to live with her sister, while her
mother lived next door. To direct enquiry, she regarded the surgery as having
been successful by virtue of improved seizure control. She was attempting to
make some gains in her level of independence but was bitterly resentful of the
perceived ongoing overmanagerial behavior of others and her failure to be
eligible for a driver’s license. She was counseled at length about the nature
and course of postoperative adjustment both for herself and those close to her
and encouraged to seriously reconsider the benefits of formal psychological
support, which she declined.
At 29 months post surgery, the clinical picture remains largely unchanged:
ongoing seizures against a background of multiple, ongoing psychosocial
stressors, enmeshed relationships, chronic low mood, poor adjustment, limited
coping skills, and variable adherence/disclosure. N.M. has made no real
psychosocial gains.