Case 1 (of 4): Increasingly disruptive behavior and possible deteriorating cognitive function in a young girl with a previous right hemispherectomy.
At this year’s American Epilepsy Society Annual Meeting, the special interest group on psychosocial comorbidities presented “Diagnostic and Management Challenges in Psychosocial Comorbidities: Complex Clinical Cases.” During the session, four challenging cases were discussed by a panel of experts, supplemented by many additional comments from audience members. The panel included epileptologist Alan B. Ettinger, MD, pediatric and adolescent psychiatrist Tatiana Falcone, MD, and clinical neuropsychologists Madison Berl, PhD, and Sarah Wilson, PhD.
Case 1: This was a 12-year-old girl with a previous right hemispherectomy for right-sided hemimegalencephaly. She was seizure-free but there were concerns about her increasingly disruptive behavior and possible deteriorating cognitive function.
Cognitive outcomes after hemispherectomy were discussed. Some improvement in function may occur after surgery, but the IQ remains low-only sometimes being up into the 80s. Ultimate cognitive function depends on such factors as the etiology of the seizures, the duration of seizures before surgery (reflecting how much seizure-induced damage has occurred in other areas of the brain), and the presence of any other brain pathology.
The issue of proper interpretation of falling IQ test scores arose. Differentiating between raw scores and standardized scores will help determine whether cognitive skills are actually being lost (falling raw scores) or the cognitive function has simply plateaued, with age-related demands outpacing the child’s abilities (falling standardized scores). With hemispherectomy, only the standardized scores would be expected to fall.
Potential reasons for the girl’s increasing behavioral problems were discussed: frustration arising from awareness that she was being surpassed by peers and siblings, concomitant attention deficit hyperactivity disorder (ADHD) or autism spectrum disorder, or hormonal changes associated with puberty.
Case 2: This was a 16-year-old boy with right frontal lobe epilepsy diagnosed about 1 year previously. Major depressive disorder was diagnosed a few months before the epilepsy diagnosis. His main current problems were depressed mood, low ambition, irritability, and impulsivity. He had a family history of depression and many life stressors (eg, family conflicts, grandmother’s death, coming out as gay, few friends) that contributed to his depression. Being diagnosed with epilepsy added yet another stressor.
There was a discussion regarding whether his impulsivity and risk-taking behavior, which included walking out of the house in the winter without a coat, reflected a psychosis. Possible explanations for the behavior were frontal lobe seizures, underlying encephalitis, medication effects, major depressive disorder, or bipolar disorder.
Issues of medications were discussed. It was noted that levetiracetam may worsen depressive symptoms, and that it sometimes takes months for the mood to improve after stopping the drug. Lamotrigine was noted to be “probably the best” antiepileptic drug (AED) for many teenagers, including this boy.
Case 3: This was an 18-year-old girl who underwent right anterior temporal lobectomy 4 years previously. She had no epileptic seizures after the surgery but did experience psychogenic nonepileptic seizures (PNES) for a short time. She had been diagnosed with generalized anxiety disorder preoperatively, for which she received cognitive behavioral therapy, but after surgery she developed severe anxiety and depression, including suicidal plans.
Dr. Ettinger recommended a full psychiatric work-up before epilepsy surgery. He noted that PNES occur in 0.2%–8.8% of individuals after this surgery, especially in those with a lower IQ or preoperative psychiatric disorder. Dr. Ettinger also indicated that new or worsening depression may occur postoperatively; one study reporting depression in 27% of people after epilepsy surgery. However, there are also reports of depression improving postoperatively. Similarly, anxiety may appear de novo after epilepsy surgery, or the surgery can exacerbate a preexisting anxiety disorder.
A discussion of when to discontinue antidepressants ensued. Dr. Falcone noted that this girl has a high risk of suicide (even without the epilepsy) and should continue to receive medications for 3 years after depressive symptoms have resolved. An audience member indicated that antidepressants should be continued for at least 2 years and then withdrawal considered only if there are no current or upcoming life stressors.
Case 4: This was a 33-year-old man with seizures since childhood and an extensive history of violent behavior, alcohol, and drug abuse (including marijuana, cocaine, and opioids), major depressive disorder, and ADHD. He was unemployed and currently on probation. A video recording was presented, which showed agitated, violent behavior accompanied by nonsensical speech. Concurrent EEG confirmed that this behavior was limited to the ictal period (originating in the frontal lobes, then travelling to the temporal regions).
The diagnosis of ictal psychosis was discussed, including its rarity and lack of reports in the literature. It is much less common than post-ictal psychosis.
Hallucinations were noted to be common in ictal psychosis. Repeated episodes of bizarre behavior that tend to begin in the same way each time can be a good clue to the diagnosis.
Baslet G, Jones JE, coordinators, Diagnostic and Management Challenges in Psychosocial Comorbidities: Complex Clinical Cases, 2016, American Epilepsy Society Annual Meeting, www.aesnet.org.