Psychiatric changes after stereotactic laser amygdalohippocampotomy for medial temporal lobe epilepsy.

PURPOSE: Stereotactic laser amygdalohippocampotomy (SLAH) is a minimally invasive surgical treatment for drug-resistant temporal lobe epilepsy (TLE) that has comparable rates of seizure freedom to traditional open resective TLE surgery. The objective of this study was to determine psychiatric outcome (i.e., depression and anxiety changes, psychosis) after SLAH, to explore possible contributory factors to these changes, and to determine the prevalence of de novo psychopathology. METHODS: We explored mood and anxiety in 37 adult patients with TLE undergoing SLAH using the Beck psychiatric symptoms scales (i.e., Beck Depression Inventory-II [BDI-II] and Beck Anxiety Inventory [BAI]) preoperatively and 6 months following surgery. Multivariable regression analysis was conducted to identify predictors of worse depression or anxiety symptoms following SLAH. The prevalence of de novo psychopathology following SLAH was also determined. RESULTS: We found a significant decrease in BDI-II (mean decline from 16.3 to 10.9, p = 0.004) and BAI (mean decline from 13.3 to 9.0, p = 0.045) scores following SLAH at the group level. While the rate of resolution of depression (from 62% to 49%) did not achieve statistical significance (p = 0.13, McNemar's), the rate of resolution of anxiety (from 57% to 35%) was statistically significant (p = 0.03, McNemar's). The de novo rate of psychopathology (i.e., new onset depression or anxiety) following SLAH was 1 of 7 (14%). Using a metric of meaningful change rather than complete symptom resolution, 16 of 37 (43%) patients experienced improvement in depression and 6 of 37 (16%) experienced worsening. For anxiety, 14 of 37 (38%) experienced meaningful improvement and 8 of 37 (22%) experienced worsening. Baseline performance on the Beck Scales was the only factor contributing to outcome status. DISCUSSION: In one of the first studies to evaluate psychiatric outcomes after SLAH, we found promising overall trends toward stability or significant improvement in symptom burden at the group level for both depression and anxiety. There was also a significant improvement in clinical anxiety, though the decrease in clinical depression was not significant, likely owing to the limitations of sample size. SLAH may improve overall psychiatric symptoms, similarly to traditional resective TLE surgery, but de novo psychopathology and postoperative psychiatric morbidity remain significant issues, and larger samples are necessary to determine causal contributory factors.

Case study of invalid to valid shift in cognitive performance following successful treatment of psychogenic nonepileptic seizure events.

Patients with psychogenic nonepileptic seizure (PNES) who fail performance validity testing (PVT) may appear to produce non-valid cognitive profiles. Consequently, they may not get referred to treatment and events persist, with worsening disability and high resource utilization. As a result, we report pre- and post-treatment neuropsychological evaluation findings in a 59-year-old woman with a confirmed diagnosis of PNES established using video-EEG monitoring. At pre-treatment baseline neuropsychological evaluation, PNES events occurred weekly to daily. Performance was impaired across PVTs and across multiple cognitive domains. After behavioral intervention specific to PNES, these events substantially reduced in frequency to rare stress-induced flares. Post-treatment neuropsychological evaluation revealed marked improvement of most cognitive and behavioral scores from baseline, and valid PVT scores. We review predisposing, precipitating, and perpetuating factors for PNES and cognitive impairment in this case and discuss the patient's outcome from treatment. Effectively managing PNES events and dissociative tendencies while reducing unnecessary pharmacological interventions appears to have allowed this patient to function closer to her optimal state. This case illustrates the complexity of Functional Neurologic Disorder (FND) clinical presentation and challenges the assumption that suboptimal neuropsychological performance predicts poor treatment engagement and outcome. We showcase the reversibility of PNES and cognitive manifestations of FND using targeted psychotherapeutic interventions, which resulted in reduced disability and associated healthcare costs, as well as re-engagement in life.

The role of oxytocin signaling in depression and suicidality in returning war veterans.

Many war veterans struggle with depression and suicidality, and separation from the military is a time of particularly high risk. Based on research in non-human animals, we hypothesized that reduced oxytocin signaling would mediate symptoms of depression and suicidality in war veterans recently separated from their close comrades. We also hypothesized that veterans with more frequent contact with comrades would have fewer symptoms of depression and suicidality. In this cross-sectional study, male veterans from the Iraq and Afghanistan wars (n = 86) provided blood and urine samples for measurement of peripheral oxytocin (OT) levels, as well as saliva samples for DNA extraction followed by genotyping of oxytocin receptor gene (OXTR) Single Nucleotide Polymorphisms, and CpG-methylation assessment. Participants also completed a series of mental health questionnaires and interviews. Veterans reported feeling very close to their comrades during war, and missing them greatly upon returning home. Neither peripheral OT levels nor OXTR genotypes were related to symptoms of depression or suicidality. On the other hand, methylation at OXTR CpG -924 was negatively correlated with depressive symptomology, after controlling for possible confounds. Veterans who socialized with comrades more frequently had higher levels of urinary, but not plasma OT, as well as less depressive symptomology. Social connectedness was a strong negative predictor of symptoms of both depression and suicidality, eclipsing the predictive power of other variables such as post-deployment social support, the degree to which participants reported missing their comrades, and the frequency with which they socialized with comrades. Our results suggest that veteran mental health is more impacted by lack of social connectedness than by separation from close comrades per se. While there is some evidence that OXTR methylation relates to depressive symptomology, decreased OT signaling does not appear to mediate the relationship between social disconnectedness and depression or suicidality. Sleep quality and anxiety disorders were also significantly associated with mental health symptoms, independent of social connectedness. Our findings suggest that efforts aimed at alleviating the burden of depression and suicidality in returning war veterans should focus on re-integrating veterans into society and establishing a feeling of social connectedness, as well as on treating anxiety disorders and sleep problems.